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A  MANUAL 


MODERN   SURGERY 


GENERAL  AND   OPERATIVE 


BY 


JOHN   CHALMERS  DaCOSTA,  M.D. 

Clinical  Professor  of  Surgery,  Jefiferson  Medical  College,  Philadelphia; 
Surgeon  to  the  Philadelphia  Hospital,  etc. 


WITH    386   ILLUSTRATIONS 


PHILADELPHIA 
W.    B.    SAUNDERS 

925  Walnut  Street 
I  898 


Copyright,  1898,  by 
W.    B.    SAUNDERS. 


ELECTROTYPED    BY  PRESS    OF 

WESTCOTT  &  THOMSON,   PHILADA.  W.  B.  SAUNDERS,   PHILADA. 


THIS   VOLUME  IS 
DEDICATED,   WITH   AFFECTIONATE   REGARDS,   TO 

DR.  ORVILLE    HORWITZ. 

THE  FELLOW-STUDENT,   THE  HOSPITAL  ASSOCIATE,  AND 
THE  TRUSTED   FRIEND   OF 

THE  AUTHOR. 


PREFACE  TO  THE   SECOND  EDITION. 


In  the  preface  to  the  first  edition  of  this  work  it  was 
stated  tliat  the  purpose  of  the  author  was  to  make  a  book 
that  would  stand  between  the  text-book  and  the  compend. 
The  very  considerable  success  that  has  been  accorded  the 
effort  seems  to  indicate  that  there  was  a  distinct  demand  for 
such  a  book.  In  the  new  edition  no  attempt  has  been  made 
to  alter  the  character  or  to  change  the  purpose  of  the 
Manual,  although  it  has  been  practically  rewritten,  many 
entirely  new  articles  added,  and  a  majority  of  the  old  articles 
enlarged,  restricted,  or  otherwise  altered.  Many  of  the 
changes  and  additions  have  been  made  in  response  to  the 
suggestions  of  reviewers  and  of  teachers  of  surgery. 

The  changes  are  numerous,  and  it  is  impossible  to  enu- 
merate them  in  this  place.  Among  them  may  be  mentioned 
the  following :  Sections  have  been  added  upon  the  Surgery 
of  the  Liver  and  Gall-Bladder,  the  Spleen,  the  Pancreas,  the 
Female  Breast,  Wounds  Inflicted  by  Modern  Projectiles, 
Electrical  Injuries,  and  the  Use  of  the  Rontgen  Rays.  The 
following  operations  have  been  described  :  Resection  of  the 
Gasserian  Ganglion ;  Methods  of  Gastrostomy ;  Schede's 
Operation  of  Thoracoplasty  ;  Use  of  the  Murphy  Button  ; 
various  new  methods  of  Enterorrhaphy ;  Bodine's  Method 
of  Colostomy ;  Prevention  of  Hemorrhage  in  Hip-joint 
Amputation  by  Macewen's  Method  of  Aortic  Compression  J 
Edmund  Owen's  Operation  for  Harelip;  Senn's   Method  of 

Resection  of  the  Shoulder-joint,  etc. 

11 


12  PREFACE    TO    THE   SECOND   EDITION. 

As  in  the  previous  edition,  the  writings  of  other  authors 
have  been  extensively  quoted,  and  the  endeavor  has  been 
always  to  give  proper  credit. 

The  author  desires  to  extend  his  cordial  thanks  to  Mr. 

Thos.  F.  Dagney,   of  Mr.   Saunders'   editorial   department, 

for  much  valuable  aid  rendered  during  the  progress  of  the 

work   through   the   press,  and  to  Mr.   R.   W.   Greene   for 

making  the  index. 

1629  Locust  Street,  Philadelphia, 
June,  1898. 


PREFACE. 


The  aim  of  this  Manual  is  to  present  in  clear  terms 
and  in  concise  form  the  fundamental  principles,  the  chief 
operations,  and  the  accepted  methods  of  modern  surgery. 
The  work  seeks  to  stand  between  the  complete  but  cumbrous 
text-book  and  the  incomplete  but  concentrated  compend. 

Obsolete  and  unessential  methods  have  been  excluded  in 
favor  of  the  living  and  the  essential.  There  has  been  no 
attempt  to  exploit  fanciful  theories  nor  to  defend  unprovable 
hypotheses,  but  rather  the  effort  has  been  to  present  the  sub- 
ject in  a  form  useful  alike  to  the  student  and  to  the  busy 
practitioner. 

The  opening  chapter  is  devoted  to  Bacteriology  because 
the  author  profoundly  believes  that  without  some  knowledge 
of  the  vital  principles  of  this  branch  of  science  the  vast  im- 
portance of  its  truths  will  be  ill-appreciated,  and  there  will 
be  inevitable  failure  in  the  application  of  aseptic  and  anti- 
septic methods. 

Ophthalmology,  gynecology,  rhinology,  otology,  and  lar- 
yngology have  not  been  considered,  because  of  the  obvious 
fact  that  in  the  advanced  state  of  specialized  science  only  the 
specialist  is  competent  to  write  upon  each  of  these  branches. 

In  Orthopedic  Surgery  are  discussed  those  conditions 
which  must  in  the  very  nature  of  things  often  be  cared  for 
by  the  surgeon  or  the  general  practitioner  (such  as  hip-joint 
disease,  club-foot.  Pott's  disease  of  the  spine,  flat-foot,  etc.). 
The  limited  space  at  command  precluded  the  introduction  of 
a  special  division  on  diseases  of  the  female  breast.  A  large 
amount  of  space  has  been  devoted  to  Fractures  and  Dis- 
locations, the  enormous  practical  importance  of  these  sub- 
jects calling  for  their  full  discussion.  Operative  Surgery  is 
considered  in  separate  sections,  the  most  important  pro- 
cedures being  fully  described,  giving  also  the  instruments 
necessary,  and  the  positions  assumed  by  patient  and  operator. 

13 


14  PREFACE. 

This  method  has  been  adopted  to  fit  the  work  for  use  in  sur- 
gical laboratories. 

Many  systems,  manuals,  monographs,  lectures,  and  journal 
articles  have  been  consulted,  and  credit  has  been  given  in 
the  text  for  statements  and  quotations.  Special  acknowl- 
edgment is  due  to  the  American  Text-Book  of  StLvgery, 
edited  by  Keen  and  White ;  to  the  surgical  works  of 
Ashhurst,  Agnew,  the  elder  Gross,  Duplay  and  Reclus, 
Esmarch,  Albert  Koenig,  Wyeth,  and  Bryant ;  to  the  Man- 
ual of  Surgery  edited  by  Treves  ;  to  the  International  En- 
cyclopcedia  of  Surgery  edited  by  Ashhurst;  to  the  Surgical 
Pathology  of  Billroth  and  of  Bovvlby  ;  to  the  Diagnosis  of  E, 
Pearce  Gould  ;  to  the  Surgical  Dictionary  of  Heath  ;  to  the 
Rest  and  Pain  of  Hilton ;  to  the  works  on  operative  sur- 
gery of  Barker,  Jacobson,  Treves,  Stephen  Smith,  and  Joseph 
Bell ;  to  the  Minor  Surgery  of  Wharton ;  to  the  dictionary 
of  Foster  and  of  Gould ;  to  the  Principles  of  Surgery  of  Senn; 
to  the  orthopedic  writings  of  Sayre ;  to  the  work  on  Diseases 
of  the  Male  Generative  Orgajis  of  Jacobson ;  to  the  System 
of  Genito-tirinary  Diseases  edited  by  Morrow ;  and  to  the 
treatises  on  Fractures  and  Dislocations  of  Sir  Astley  Cooper, 
Malgaigne,  Hamilton,  Stimson,  and  T.  Pickering  Pick. 

The  Author  returns  his  thanks  to  the  numerous  writers 
who  courteously  authorized  the  reproduction  of  special 
illustrations,  and  particularly  to  Professors  Keen  and  White 
for  their  free  permission  to  draw  upon  the  Americaji  Text- 
Book  of  Surgery,  from  which  a  number  of  pictures  have  been 
taken,  distinctively  those  referring  to  Bandaging;  to  Mr. 
John  Vansant  for  the  great  amount  of  labor  so  ably  and 
cheerfully  performed ;  and  to  Dr.  Howard  Dehoney  for 
the  preparation  of  the  Index, 

2050  Locust  Street,  Philadelphia, 
October,  1894. 


CONTENTS. 


PAGE 

I.  Bacteriology 17 

II.  Asepsis  and  Antisepsis 42 

III.  Inflammation 48 

IV.  Repair 82 

V.  Surgical  Fevers 87 

VI.  Terminations  of  Inflammation .  90 

VII.  Ulceration  and  Fistula no 

VIII.  Mortification  or  Gangrene 119 

IX.  Thrombosis  and  Embolism 132 

X.  Septicemia  and  Pyemia 136 

XI.  Erysipelas  (St.  Anthony's  Fire) 140 

XII.  Tetanus  or  Lockjaw 144 

XIII.  Tuberculosis  and  Scrofula. 148 

XIV.  Rickets 158 

XV.  Contusions  and  Wounds 160 

XVI.  Syphilis     1S4 

XVII.  Tumors,  or  Morbid  Growths 209 

XVIII.  Diseases  and  Injuries  of  the  Heart  and  Vessels    .    .    .  239 

1.  Hemorrhage  or  Loss  of  Blood 258 

2.  Operations  on  the  Vascular  System 274 

3.  Ligation  of  Arteries  in  Continuity 278 

XIX.  Diseases  and  Injuries  of  Bones  and  Joints 309 

1.  Diseases  of  the  Bones 309 

2.  Fractures 321 

3.  Diseases  of  the  Joints 406 

4.  Luxations  or  Dislocations 438 

5.  Operations  upon  Bones 475 

XX.  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Burs^  .    .  504 

Operations  upon  Muscles  and  Tendons 516 

XXI.  Orthopedic  Surgery 519 

XXII.  Diseases  and  Injuries  of  Nerves 527 

1.  Diseases  of  Nerves 527 

2.  Wounds  and  Injuries  of  Nerves 528 

3.  Operations  upon  Nerves 530 

15 


1 6  CONTENTS. 

PAGE 

XXIII.  Diseases  and  Injuries  of  the  Head 535 

1.  Diseases  of  the  Head 535 

2.  Injuries  of  the  Head 543 

XXIV.  Surgery  of  the  Spine 577 

XXV.  Surgery  of  the  Respiratory  Organs 596 

1.  Diseases  and  Injuries  of  the  Nose  and  Antrum  ....  596 

2.  Diseases  and  Injuries  of  the  Larynx  and  Trachea  .    .    .  59^ 

3.  Operations  on  the  Larynx  and  Trachea 600 

4.  Diseases  and  Injuries  of  the  Chest,  Pleura,  and  Lungs  .  605 
XXVI.  Diseases  and  Injuries  of  the  Upper  Digestive  Tract  612 

XXVII.  Diseases  and  Injuries  of  the  Abdomen 626 

1.  Stomach  and  Intestines 633 

2.  The  Peritoneum 655 

3.  The  Liver  and  Gall-bladder 658 

4.  The  Pancreas 664 

5.  The  Spleen •-....  665 

6.  Operations  upon  the  Abdomen  .        666 

XXVIII.  Diseases  and  Injuries  of  the  Rectum  and  Anus    .    .  713 

XXIX.  Anesthesia  and  Anesthetics 725 

XXX.  Burns  and  Scalds 73^ 

XXXI.  Diseases  of  the  Skin  and  Nails 739 

XXXII.  Diseases  and  Injuries  of  the  Thyroid  Gland  ....  743 

XXXIII.  Diseases  and  Injuries  of  the  Lymphatics 746 

XXXIV.  Bandages 748 

XXXV.  Plastic  Surgery 759 

XXXVI.  Diseases  and  Injuries  of  the  Genito-urinary  Organs  763 

1.  Diseases  and  Injuries  of  the  Kidney  and  Ureter     ...  768 

2.  Diseases  and  Injuries  of  the  Bladder 784 

3.  Diseases  and  Injuries  of  the  Urethra,  Penis,  Testicles, 
Prostate,  Seminal  Vesicles,  Prostatic  Cord,  and  Tunica 
Vaginalis 810 

XXXVII.  Amputations 841 

Special  Amputations 847 

XXXVIII.  Diseases  of  the  Breast 859 

XXXIX.  Skiagraphy,  or  the  Employment  of  the  RontCen  Rays  871 

XL.  Injuries  by  Electricity 878 


INDEX 


Modern  Surgery. 


I.    BACTERIOLOGY. 


Bacteriology  is  the  science  of  micro-organisms.  Though 
a  science  in  the  youth  of  its  years,  bacteriology  has  not  only 
profoundly  altered,  but  it  has  also  revolutionized,  pathology, 
and  our  views  of  surgery  will  be  incomplete,  misleading, 
and  erroneous  without  its  aid. 

Micro-organisms,  microbes,  or  bacteria,  are  minute 
vegetable  cells  of  the  class  fniigi,  many  of  them  being  vis- 
ible only  by  means  of  a  highly  powerful  microscope  after 
they  have  been  brightly  stained.  The  contents  of  these  cells 
are  protoplasm  and  nuclear  chromatin  enclosed  by  a  structure 
containing  cellulose.  The  protoplasm  can  be  stained  with 
anilin  colors,  and  the  cell-wall  is  more  readily  detected  after 
treating  it  with  water,  which  causes  it  to  swell.  Many  or- 
ganisms are  colored,  others  are  colorless.  Some  move  (mo- 
tile bacteria),  others  do  not  move  (amotile  bacteria) ;  among 
the  motionless  ones  may  be  mentioned  the  bacilli  of  anthrax 
and  tubercle,  and  all  cocci.  Many  bacteria  can  change 
from  motile  to  amotile  or  from  amotile  to  motile  when  sub- 
jected to  changed  conditions  of  life.  The  oscillations  of 
cocci  are  physical  and  not  vital  in  nature;  they  are  Brun- 
onian  movements,  movements  due  to  alterations  in  equilib- 
rium because  of  currents  or  changes  of  level  in  the  fluid  in 
which  the  organisms  are  held.  Bacteria  possess  the  power 
of  attracting  elements  necessary  for  their  nutrition  and  of 
repelling  elements  antagonistic  to  them  (chemiotaxis  or 
chemotaxis). 

Definite  knowledge  of  these  minute  bodies  and  of  their 
actions  dates  from  the  study  of  fermentation  by  the  cele- 
brated Frenchman  Pasteur,  who  in  1858  asserted  that  every 
fermentation  has  invariably  its  specific  ferment ;  that  this 
ferment  consists  of  living  cells  ;  that  these  cells  produce  fer- 
mentation by  absorbing  the  oxygen  of  the  substance  acted 
upon ;  that  putrefaction  is  caused  by  an  organized  ferment ; 
2  17 


l8  MODERN  SURGERY. 

that  all  organized  ferments  are  carried  about  in  the  air ;  and 
that  to  entirely  exclude  air  prevents  putrefaction  or  fermenta- 
tion. These  statements,  which  were  radical  departures  from 
accepted  belief,  inaugurated  a  bitter  controversy,  and  in  that 
controversy  were  born  the  microbic  theory  of  disease,  the 
doctrine  of  preventive  inoculation,  antiseptic  surgery,  and 
serum-therapy. 

The  word  microbe,  which  signifies  a  small  living  being,  was 
introduced  in  1878  by  the  late  Professor  Sedillot,  of  Paris.  At 
that  time  the  nature  of  these  bodies  was  in  doubt ;  some 
thought  them  animal,  and  called  them  microzoaria ;  others 
thought  them  vegetable,  and  called  them  inicvophyta ;  the 
designation  "  microbe  "  does  not  commit  us  to  either  view. 
We  now  know  them  to  be  vegetable,  but  the  term  "  mi- 
crobe "  has  remained  in  use. 

The  fungi  connected  with  disease  in  man  are  divided  into 
three  classes : 

1.  Yeasts,  Saccharomyces,  or  Blastomycetes ; 

2.  Moulds,  or  Hyphomycetes  ; 

3.  Bacteria,  or  Schizomycetes. 

Yeasts  include  most  of  those  fungi  which  can  cause  alco- 
holic fermentation  in  saccharine  matter.  They  consist  of  small 
cells  which  multiply  by  gemmation  and  which  can  live  with- 
out free  oxygen.  These  cells  often  stick  together  and  form 
branches,  and  contain  spores  when  nourishment  is  insufficient. 
They  are  thought  to  be  vegetative  forms  of  higher  fungi 
(Green).  The  chief  importance  of  yeasts  is  that  they  cause 
fermentation ;  they  never  invade  human  tissues,  though  they 
can  dwell  on  mucous  membranes,  and  even  in  the  stomach. 
O'idium  albicans  is  an  yeast-fungus  whose  growth  upon  the 
mucous  membrane  of  the  mouth,  pharynx,  and  esophagus 
causes  the  disease  known  as  "  thrush."  Pekelharing  says 
that  pityriasis  capitis  is  due  to  the  saccharomyces  capillitii. 

Moulds  consist  of  filaments,  each  filament  being  composed 
of  a  single  row  of  cells  arranged  end  to  end,  and  all  filaments 
springing  from  a  germinal  tube  which  grows  from  a  germi- 
nating spore.  Moulds  are  largely  connected  with  processes 
of  decay.  Some  of  them  grow  upon  inflamed  mucous  mem- 
brane, and  some  invade  the  epidermis,  producing  certain  skin 
diseases  (favus,  tinea  tonsurans,  tinea  versicolor,  etc.). 

Actinomycosis  and  Madura-foot  arise  from  the  lodgement 
and  growth  of  moulds  (Fig.  i).  Actinomycosis  is  a  disease 
seen  in  cattle,  and  occasionally  in  men,  especially  in  drovers. 
Cattle  become  infected  usually  through  their  food,  the  fun- 
gus entering  by  a  hollow  tooth  or  by  a  breach  of  continuity 


BACTERIOLOGY. 


19 


in  mucous  membrane.  The  lower  jaw  is  usually  the  seat  of 
involvement  in  cattle  (lumpy  jaw).  A  tumor  forms,  which  con- 
tains sero-pus,  and  after  a  time  ruptures  and  discharges  mat- 
ter containing  nodules  composed  of  fungi.  The  bone  may 
undergo  extensive  destruction. 
Other  bones  and  various  organs 
may  be  infected. 

Madura-foot  or  mycetoma  is  an 
endemic  disease  of  India,  which  is 
probably  due  to  infection  with 
the  Chionypha  Carted.  The  foot 
swells  and  becomes  covered  with 

,  ,  ,  Fig.  I. — Actinomyces  (Ziegler). 

pustules  ;  the  pustules  rupture  and 

expose  sinuses  ;  each  sinus  is  lined  with  a  firm  membrane  and 
is  filled  with  material  which  looks  like  the  roe  of  a  fish.  The 
bones  are  often  extensively  destroyed,  and  gangrene  not  un- 
commonly arises. 

Bacteria  chiefly  claim  our  attention.  It  is  important  to 
remember  that  the  term  "  bacteria,"  though  applied  to  the 
class  scJiizoinycctcs,  has  also  a  more  restricted  application — 
that  is,  to  a  division  of  the  class ;  it  may  mean  either  schizo- 
viycctcs  in  general,  or  rod-shaped  scliizoviycctcs,  whose  length 
is  not  more  than  twice  their  breadth. 

Some  of  the  scJiizoinycctcs  induce  certain  fermentations  ; 
others  grow  upon  dead  organic  matter,  but  are  not  able  to 
invade  living  tissues,  and  are  called  sapropJiytcs  or  non- 
pathogenic bacteria  ;  still  others,  known  as  the  pathogenic, 
cause  various  diseases.  Parasitic  bacteria  can  grow  on  or  in 
the  tissues  of  the  body.  Obligate  parasites  are  those  which 
have  not  been  cultivated  outside  of  the  body  (as  the  bacilli 
of  leprosy).  Facultative  parasites  usually  live  outside  the 
body,  but  may  enter  into  the  body  and  produce  disease. 
The  schizomycetes  vary  much  in  shape,  size,  color,  arrange- 
ment, mode  of  growth,  and  action  upon  the  body.  One 
form  cannot  be  transformed  into  another,  but  each  main- 
tains its  specific  identity.  Every  organism  comes  from  a 
pre-existing  organism,  this  being  true  of  all  forms,  as  spon- 
taneous generation  is  impossible. 

Forms  of  Bacteria. — The  three  chief  forms  of  bacteria 
are — 

1.  The  Coccus  or  Micrococcus — berry-shaped,  oval,  or 
round  bacterium  (Fig.  2) ; 

2.  The  Bacillus — rod-shaped  bacterium  (Fig.   3) ; 

3.  The  Spirillum — corkscrew-shaped  or  spiral  bacterium 
(Fig.  4).     A  short  spiral  is  called  a  comma  bacillus. 


20  MODERN  SURGERY. 

De  Baiy  compares  these  forms,  respectively,  to  the  bil- 
liard-ball, the  lead-pencil,  and  the  corkscrew. 

Cocci  and  Bacilli. — We  have  to  do  only  with  cocci  and 
bacilli.  Cocci  may  be  designated  according  to  their  arrange- 
ment with  one  another ;  namely,  when  existing  singly  they 


Fig.  2. — Micrococcus.  Fig.  3. — Bacillus.  Fig.  4. — Spirillum. 

are  called  monococci ;  in  pairs  they  are  called  diplococci  (Fig. 
5,  a);  in  a  chain  they  are  called  streptococci  (Fig.  5,  c);  in  a 
cluster  Hke  a  bunch  of  grapes  they  are  called  staphylococci . 
(Fig.  5,  b)  ;  in  groups  of  four  they  are  called  tetracocci ;  m 
groups  of  eight  they  are  called  sarcina  or  wool-sack  cocci. 
Irregular  masses,  resembling  frog-spawn,  constitute  zooglea 
masses  (Fig.  6).  The  gelatinous  matter  in  such  a  mass  is 
formed  by  a  transformation  in  the  walls  of  the  bacteria.  The 
term  ascococci  is  applied  to  a  group  of  cocci  enclosed  in  a 
capsule  (G.  S.  Woodhead). 

The  cocci  are  often  named  according  to  their  function,  as. 


'>:^ 


.-<.••-     r— •'•5 


C<^': 


c 

Fig.  5.— Forms  of  cocci.  Fig.  6.— Zooglea  (Ball). 

for  example,  "pyogenic,"  or  pus-forming.  Cocci  may  be 
named  according  to  the  color  of  the  culture.  The  name 
may  embody  the  form,  arrangement,  color,  and  function ;  for 
instance,  staphylococc2is  pyogenes  aureus  signifies  a  round, 
golden-yellow  micro-organism,  which  arranges  itself  with  its 


BACTERIOLOGY. 


21 


fellows  into  the  form  of  a  bunch  of  grapes,  and  which  pro- 
duces pus. 

The  bacilli  are  long,  staff-shaped  organisms.  Long  bacilli 
having  a  wavy  outline  are  called  leptothrix.  Chain-like  ba- 
cilli are  called  strepto-bacilli.  Bacilli  give  origin  to  many 
surgical  diseases. 

Multiplication  of  Bacteria.— Bacteria  multiply  with 
great  rapidity  when  placed  under  suitable  conditi(jns.  They 
can  multiply  by  fission  or  by  spore-formation.  Some  bacteria 
multiply  by  both  methods.  In  fission,  or  segmentation,  the 
cell  elongates  and  about  its  middle  a  constriction  begins, 
which  deepens  until  the  cell  has  divided  into  two  parts, 
each  of  which  soon  grows  as  large  as  its  parent  (Figs.  7,  8), 


Fig.  7. — Divisions  of  a  micrococcus  (after  Mace). 


Fig.  8. — Divisions  of  a  bacillus  (after  Mace). 


All  cocci  and  some  bacilli  multiply  by  this  method.  If 
segmentation  of  a  single  cell  and  the  growth  to  maturity 
of  its  products  require  one  hour  (it  really  takes  place  in  less 
time,  the  cholera  bacillus  requiring  but  twenty  minutes  to 
divide),  a  single  cell  in  a  single  day  will  have  sixteen  million 
descendants  (Cohn).  In  order,  however,  for  such  enormous 
multiplication  to  occur  conditions  must  be  absolutely  favor- 
able to  the  cells,  and  conditions  are  rarely  absolutely  favor- 
able. Were  it  otherwise  all  other  forms  of  life  would  be 
destroyed. 

Spores. — A  spore  is  a  germ,  and  corresponds  with  the 
seed  of  a  plant.  Most  of  the  bacilli  multiply  by  spore- 
formation.  Cocci  do  not  undergo  spore-formation  after  the 
manner  of  bacilli,  though  some  observers  maintain  that 
cocci  occasionally  undergo  an  alteration  that  makes  them 
very  resistant  to  any  destructive  influences  (arthrospores). 
When  spore-formation  is  about  to  occur  in  a  bacillus  points 


MODERN  SURGERY. 


Fig.  9. — Sporulation  (after  De  Bary). 


of  cloudiness  appear  in  the  protoplasm,  the  cell  generally 
elongates,  and  in  twenty-four  hours  the  cell  is  found  to  consist 
of  a  series  of  segments  like  a  necklace  of  beads,  each  segment 
containing  a  full-grown  spore  (Fig.  9).     The  wall  of  the  cell 

now  liquefies,  the  segments 
separate,  the  spores  are  set 
free,  and  each  spore  under 
favorable  conditions  be- 
comes a  bacillus.  When 
ffl    1^  0     ^      \a)  ^      m  ^^^    initial    cloudiness    ap- 

'^'  '^  ^      pears  in  the  middle  of  the 

cell  it  is  called  an  "  endo- 
spore ;"  when  it  appears  at 
one  or  both  extremities  it 
is  christened  an  "  end- 
spore  "  or  "  endspores." 
When  multiplication  is  by 
a  single  endospore  the  ba- 
cillus does  not  elongate. 
Organisms  which  when  active  multiply  by  fission  take  on 
spore-formation  when  subjected  to  certain  conditions. 

Spore -formation  tends  to  occur  when  bacilli  are  about  to 
die  for  want  of  nourishment  or  when  there  is  an  excess  of 
oxygen  present.  Each  cell,  as  a  rule,  contains  but  one  spore, 
but  may  contain  several.  The  spore  has  a  dense  envelope 
or  covering  which  is  very  resistant  to  destructive  agents.  So 
resistant  is  the  covering  that  twice  the  amount  of  heat  is 
necessary  to  kill  a  spore  as  to  kill  an  active  adult  cell. 
Spores  when  placed  under  conditions  unfavorable  for  devel- 
opment may  remain  inactive  for  an  indefinite  period,  just  as 
seeds  remain  inactive  when  unplanted.  When  spores  en- 
counter favorable  conditions  they  at  once  develop  into  adult 
cells,  just  as  seeds  develop  when  planted.  It  seems  prob- 
able that  spores  occasionally  remain  dormant  in  the  human 
body  for  long  periods,  and  finally  awaken  into  activity  be- 
cause of  injury  or  disease  of  the  tissue  in  which  they  lie. 
lyife-conditions  of  Bacteria. — In  order  to  grow  and 
to  multiply,  bacteria  require  a  suitable  soil  and  the  favoring 
influences  of  heat  and  moisture.  The  soil  demanded  con- 
sists of  highly  organized  compounds  rather  than  crude  sub- 
stances, and  slight  modifications  in  it  may  prove  fatal  to 
some  forms  of  bacterial  life,  but  highly  advantageous  to 
others.  Some  organisms  require  albuminous  matter,  others 
need  carbohydrates  ;  they  all  require  water,  carbon,  nitrogen, 
oxygen,  hydrogen,  and  certain  inorganic  materials,  especially 


BACTERIOLOGY.  23 

lime  and  potassium  (Woodliead).  All  organisms  require 
water.  If  dried,  no  form  will  multiply,  and  many  forms  will 
die.  The  fluids  and  tissues  of  the  individual  may  or  may 
not  afford  a  favorable  soil  for  the  germs  of  a  disease,  or,  in 
the  same  person,  may  afford  it  at  one  time,  and  not  at  an- 
other. Some  individuals  seem  to  possess  indestructible  im- 
munity from,  and  others  are  especially  prone  to,  certain  con- 
tagious diseases.  Impairment  of  health,  by  altering  some 
subtle  condition  of  the  soil,  may  make  a  person  liable  who 
previously  was  exempt. 

The  presence  of  oxygen  influences  microbic  growth.  Most 
organisms  thrive  best  when  exposed  to  the  oxygen  of  the 
air,  and  they  are  known  as  "  aerobic."  The  term  "  anaero- 
bic "  is  employed  to  designate  organisms  that  can  grow  and 
multiply  and  produce  particular  products  only  when  air  is 
absent,  free  oxygen  being  fatal  to  them.  The  tetanus  bacil- 
lus and  the  bacillus  of  malignant  edema  are  anaerobic.  An 
organism  which  can  grow  indifferently  where  oxygen  is  abun- 
dant or  where  free  oxygen  is  absent  is  called  a  "  faculta- 
tive-aerobic"  bacterium.  It  may  need  oxygen;  but  if  it  does, 
it  is  able  to  obtain  it  from  the  tissues  when  air  is  excluded. 
A  sensitive  organism  which  dies  when  the  amount  of  oxygen 
is  even  slightly  diminished  is  called  an  "  obligate-aerobic  " 
bacterium.  Most  microbic  diseases  in  man  are  due  to  facul- 
tative-aerobic bacteria. 

Effect  of  Motion,  Sunlight,  Heat,  and  Cold.— The 
majority  of  fungi  grow  best  when  at  rest;  agitation  retards 
the  growth  of  some  and  kills  others.  Sunlight  antagonizes 
the  growth  of  certain  bacteria.  Temperature  influences  bac- 
terial growth.  Some  organisms  will  only  grow  within  narrow 
temperature-limits,  while  others  can  sustain  sweeping  altera- 
tions, but  most  grow  best  between  the  limits  of  from  86°  to 
104°  F.  Freezing  renders  bacteria  motionless  and  incapa- 
ble of  multiplication,  but  it  does  not  kill  them :  they  again 
become  active  when  the  temperature  is  raised.  The  absurd- 
ity of  employing  cold  as  a  germicide  is  evident  when  the  fact 
is  known  that  a  temperature  of  200°  F.  below  zero  is  not 
fatal  to  germ-life,  cell-activities  by  such  a  temperature  only 
being  rendered  dormant.  High  temperatures  are  fatal  to 
bacteria ;  moist  heat  is  more  destructive  than  dry  heat,  and 
adult  cells  are  more  easily  killed  than  spores.  A  temperature 
less  than  212°  F.  will  kill  many  organisms,  and  boiling  will 
kill  every  pathogenic  organism  that  does  not  form  spores. 
Some  spores  are  not  destroyed  after  prolonged  boiling,  and 
some  will  withstand  a  temperature  of  120°  C.    As  a  practical 


24  MODERN  SURGERY. 

fact,  however,  boiling  water  kills  in  a  few  minutes  all  cocci, 
most  bacilli,  and  all  pathogenic  spores  ;  though  the  spores 
of  anthrax,  tetanus,  and  malignant  edema  are  harder  to  kill 
than  are  the  spores  of  other  bacteria. 

Chemical  Germicides. — Many  chemical  agents  will  kill 
bacteria,  the  most  certain  of  them  all  being  corrosive  subli- 
mate. Koch  showed  that  corrosive  sublimate  is  an  efficient 
test-tube  germicide  when  present  in  the  proportion  of  only 
I  part  to  50,000.  It  is  used  in  surgery  in  strengths  of  i  part 
of  the  salt  to  1000,  2000,  3000,  or  more  parts  of  water.  Badly 
infected  wounds  are  occasionally  irrigated  with  solutions  of  a 
strength  of  i  to  500.  Contact  with  albumin  precipitates  from 
a  solution  of  corrosive  sublimate  an  insoluble  albuminate  of 
mercury.  In  surgical  operations  by  the  wet  method  the  mer- 
cury may  be  combined  with  tartaric  acid  in  the  proportion 
of  I  to  5,  which  combination  prevents  the  insoluble  albumi- 
nate from  being  formed. 

But  though  corrosive  sublimate  under  certain  conditions 
is  very  powerful,  it  is  not  always  absolutely  reliable.  Many 
spores  are  very  resistant  to  its  action.  Even  a  i  per  cent, 
solution  of  bichlorid  of  mercury  is  not  certainly  destructive 
of  the  .spores  of  anthrax.  Geppert  tells  us  that  anthrax-spores 
may  be  active  after  a  25-hour  immersion  in  a  i  :  100  solution 
of  sublimate  (Schimmelbusch).  In  the  presence  of  hydrogen 
sulphide  corrosive  sublimate  is  useless,  inert  and  insoluble, 
sulphide  of  mercury  being  precipitated  ;  hence  corrosive  sub- 
Hmate  is  without  value  as  a  rectal  antiseptic;  in  fact,  Gerl- 
oczy  has  proved  that  a  concentrated  aqueous  solution  of 
sublimate  will  not  disinfect  an  equal  quantity  of  feces.  Cor- 
rosive sublimate  contained  in  dressings  after  a  time  undergoes 
decomposition  and  ceases  to  be  a  germicide.  It  is  not  ger- 
micidal in  fatty  tissues  because  it  is  unable  to  attack  bacteria 
which  are  coated  with  oil.  Corrosive  sublimate  is  very  irri- 
tating to  the  tissues  and  causes  copious  exudation.  Hence, 
after  tissues  have  been  irrigated  with  this  agent  drainage 
must  be  employed.  In  some  cases  the  irritated  tissues  lose 
to  a  great  extent  their  power  of  resistance,  and  infection  may 
be  actually  facilitated  by  irrigation  with  sublimate.  In  rare 
instances  corrosive  sublimate  is  absorbed  and  produces  poi- 
soning. In  spite  of  these  shortcomings  and  drawbacks  it  is 
a  valuable  aid  to  the  surgeon  and  must  be  frequently  used, 
especially  upon  the  skin  of  the  patient  and  the  hands  of  the 
operator  and  his  assistants.  It  should  be  dissolved  in  dis- 
tilled water,  because  ordinary  water  causes  a  precipitate  to 
form  (common  salt  prevents  the  formation  of  this  precipitate). 


BACTERIOLOGY.  2$ 

Because  of  the  facts  that  corrosive  subHmate  is  poisonous 
and  very  irritant  and  that  serous  membranes  quickly  absorb 
it,  this  agent  should  not  be  used  upon  serous  membranes. 
It  is  very  irritant  to  joints,  and  many  surgeons  will  not  in- 
troduce it  into  them.  It  should  never  be  put  within  the 
dura,  and  should  not  be  applied,  in  strong  solution  at  least, 
to  mucous  membranes.  It  is  better  to  make  the  solution 
when  it  is  needed,  so  as  to  have  it  fresh,  for  in  old  solutions 
much  of  the  soluble  corrosive  sublimate  has  been  converted 
into  insoluble  calomel,  and  the  fluid  has  ceased  to  be  germi- 
cidal. In  order  to  make  up  fresh  solutions  use  tablets,  each 
of  which  contains  about  y}4  grains  of  the  drug — one  of 
these  tablets  added  to  a  pint  of  water  makes  a  solution  of  a 
strength  of  i  to  lOOO.  Tablets  which  also  contain  ammo- 
nium chlorid  are  more  soluble  than  those  which  contain 
corrosive  sublimate  only.  Hot  solutions  of  the  drug  are 
more  powerfully  germicidal  than  cold  solutions.  As  corro- 
sive sublimate  is  irritant,  leads  to  profuse  exudation,  and  may 
produce  tissue-necrosis,  it  should  never  be  introduced  into 
an  aseptic  wound. 

Griffin,  in  Foster's  Practical  Therapeutics,  sets  forth  the 
strengths  of  solutions  applicable  to  different  regions. 

For  disinfection  of  the  surgeon's  hands  and  the  patient's 
skin,  I  :  lOOO;  for  irrigating  trivial  wounds,  i  :  2000 ;  for  irri- 
gating larger  wounds  and  cavities,  i  :  5000  to  i  :  10,000;  for 
irrigating  vagina,  i  :  5000  to  i  :  10,000;  for  irrigating  urethra, 
I  :  20,000  to  I  :  40,000  ;  for  irrigating  conjunctiva,  i  :  5000 ;  for 
gargling,  i  :  5000  to  i  :  10,000. 

Instruments  cannot  be  placed  in  corrosive  sublimate  with- 
out being  dulled,  stained,  and  corroded. 

Corrosive  sublimate  may  be  absorbed  from  a  wound,  a 
serous  surface,  or  a  mucous  membrane,  ptyalism  and  diar- 
rhea resulting.  The  absorption  of  bichlorid  of  mercury 
may  be  followed  by  cramp  in  the  limbs  and  belly,  feeble 
pulse,  cold  skin,  extreme  restlessness,  and  even  death  by 
collapse.  At  the  first  sign  of  trouble  withdraw  the  drug 
and  treat  the  ptyalism  (p.  202). 

Carbolic  acid  is  a  valuable  germicide  in  the  strength  of 
from  I  :  40  to  i  :  20.  It  is  certainly  fatal  to  pus-organisms, 
but  weak  solutions  do  not  destroy  spores.  Unfortunately, 
this  acid  attacks  the  hands  of  the  surgeon  ;  consequently  in 
the  United  States  it  is  chiefly  employed  as  an  antiseptic  me- 
dium in  which  to  place  the  sterilized  operating-instruments, 
or  as  a  germicide  to  prepare  the  skin  of  the  patient  before 
the  operation  is  performed. 


26  MODERN  SURGERY. 

Carbolic  acid  is  very  irritant  to  tissues,  and  carbolized 
dressings  may  be  responsible  for  sloughing  of  the  wound. 
Because  of  its  irritant  properties  wounds  which  have  been 
irrigated  with  it  should  be  well  drained.  Carbolic  acid,  like 
corrosive  sublimate,  is  inert  in  fatty  tissues.  Carbolic  acid 
is  readily  absorbed,  and  may  thus  produce  toxic  symptoms. 
Absorption  is  not  uncommon  when  the  weaker  solutions  are 
used,'  but  rarely  occurs  when  a  wound  has  been  brushed 
over  with  pure  acid,  because  the  pure  acid  at  once  forms  an 
extensive  zone  of  coagulation,  which  acts  as  a  barrier  to  ab- 
sorption. One  of  the  early  indications  of  the  absorption  of 
carbolic  acid  is  the  assumption  by  the  urine  of  a  smoky, 
greenish  or  blackish  hue.  Examination  of  such  smoky  urine 
shows  a  great  diminution  or  entire  absence  of  sulphates  when 
the  acidulated  urine  is  heated  with  chlorid  of  barium.  This 
diminution  of  precipitable  sulphates  is  explained  by  the  fact 
that  these  salts  are  combined  with  carbolic  acid,  forming  sol- 
uble sulphocarbolates  (Griffin).  Such  urine  is  apt  to  contain 
albumin.  If  during  the  use  of  carbolized  dressing  or  the 
employment  of  carbolic  solutions  the  urine  becomes  smoky, 
the  use  of  the  drug  in  any  form  must  be  at  once  discon- 
tinued, otherwise  dangerous  symptoms  will  soon  appear. 
These  symptoms  are  subnormal  temperature,  feeble  pulse 
and  respiration,  muscular  weakness,  and  vertigo.  If  death 
occurs,  it  is  due,  as  a  rule,  to  respiratory  failure.  The  treat- 
ment of  slow  poisoning  by  carbolic  acid  consists  in  at  once 
withdrawing  the  drug,  giving  stimulants  and  nourishing  food, 
and  administering  sulphate  of  sodium  several  times  a  day  and 
atropin  in  the  morning  and  evening. 

Pure  carbolic  acid  is  a  reliable  disinfectant  for  certain  con- 
ditions. It  is  used  to  destroy  chancroids,  to  purify  infected 
areas,  to  disinfect  the  medullary  cavity  in  osteomyelitis,  to 
stimulate  granulation  after  the  open  operation  for  hydrocele, 
or  to  purify  sloughing  burns.  The  pure  acid  will  not  pro- 
duce constitutional  symptoms,  but  it  occasionally  causes 
sloughing.  Its  application  causes  pain  for  a  moment  only, 
and  then  analgesia  ensues.  Even  dilute  solutions  of  carbolic 
acid  greatly  relieve  pain  when  applied  to  raw  surfaces. 

Carbolic  acid  is  certainly  fatal  to  but  few  bacteria  and  it 
fails  to  kill  most  spores.  It  acts  more  slowly  and  less  cer- 
tainly than  corrosive  sublimate.  It  requires  24  hours  for  a 
5  per  cent,  solution  to  kill  anthrax-spores.  Pus  or  blood 
(albuminous  matter)  greatly  weakens  the  germicidal  power 
of  carbolic  acid,  and  fatty  tissue  cannot  be  disinfected  by  it. 
It  is  not  even  the  best  of  agents  in  which  to  place  instru- 


BACTERIOLOGY.  2/ 

ments,  as  it  dulls  them.  After  operation  upon  the  mouth  it 
is  used  as  a  wash  or  gargle,  i  to  2  per  cent,  being  a  suitable 
strength.  It  is  used  sometimes  to  irrigate  the  bladder  and 
often  to  cleanse  sinuses,  but  is  not  employed  in  the  perito- 
neal cavity  or  the  brain.  It  is  occasionally  injected  into  tu- 
berculous joints. 

Kreolin,  which  is  a  preparation  made  from  coal-tar,  is  a 
germicide  without  irritant  or  toxic  effects.  It  is  less  power- 
ful than  carbolic  acid  but  acts  similarly,  and  is  used  in  emul- 
sion of  a  strength  of  from  i  to  5  per  cent.,  and  does  not  irri- 
tate the  skin  like  carbolic  acid. 

Peroxid  of  hydrogen  is  a  most  admirable  agent  for  the 
destruction  of  pus  cocci.  It  comes  in  a  15-volume  solution, 
which  is  diluted  one-half  or  two-thirds.  It  probably  destroys 
the  albuminous  element  upon  which  bacteria  live,  and  starves 
the  fungi.  The  pero.xide  of  hydrogen  is  not  fatal  to  tetanus 
bacilli.  Some  surgeons  use  it  to  wash  out  appendicular  ab- 
scesses. It  must  not  be  injected  into  an  abscess  unless  a 
large  opening  exists,  as  otherwise  the  evolved  gas  may  tear 
apart  structures  and  dissect  up  the  cellular  tissue.  In  a 
deep  abscess  of  the  neck  the  author  saw  this  agent  almost 
produce  suffocation,  the  gas  passing  under  the  mucous  mem- 
brane and  nearly  blocking  the  air-passages. 

Iodoform  is  largely  used ;  it  is  not  truly  a  germicide,  as 
bacteria  will  grow  upon  it,  but  it  hinders  the  development 
of  bacteria  and  directly  antagonizes  the  toxic  products  of 
germ-life.  It  can  be  rendered  sterile  by  washing  with  a 
solution  of  corrosive  sublimate.  It  is  of  the  greatest  value 
when  applied  to  infected  areas  and  tuberculous  processes. 
Clinically,  no  real  substitute  for  it  has  yet  been  found.  It 
need  not  be  applied  to  clean  wounds,  but  the  powder  is 
very  useful  when  dusted  in  infected  wounds.  It  prevents 
wound-discharges  from  decomposing  and  greatly  allays  pain. 
Gauze  impregnated  with  iodoform  is  used  to  drain  abscesses, 
to  drain  the  belly  under  certain  circumstances,  to  pack  aside 
the  intestines  and  prevent  their  infection  during  some  abdom- 
inal operations,  and  as  packing  to  arrest  intracranial  hemor- 
rhage. Tuberculous  joints  and  cold  abscesses  are  injected 
with  iodoform  emulsion,  which  is  made  by  adding  the  drug 
to  glycerin  or  olive  oil.  The  strength  of  the  emulsion  is  10 
per  cent.  A  solution  in  ether  of  a  strength  of  10  per  cent, 
may  be  used  to  inject  the  cavity  of  a  cold  abscess. 

The  drug  must  be  used  with  some  caution.  Absorption 
from  a  wound  sometimes  happens,  producing  toxic  symptoms. 
These  symptoms  are  frequently  misinterpreted,  being  usually 


28  MODERN  SURGERY. 

attributed  to  infection.  The  symptoms  in  some  cases  are 
acute  and  arise  suddenly,  and  consist  of  a  hallucinatory  de- 
lirium, nausea,  fever,  watery  eyes,  contracted  pupils,  metallic 
taste  in  mouth,  yellowness  of  the  skin  and  eyes,  an  odor  of 
iodoform  upon  the  breadth,  the  presence  of  the  drug  in  the 
urine,  the  outbreak  of  a  skin  eruption  resembling  measles, 
and  excessive  loss  of  flesh  and  strength.  Patients  with  such 
acute  symptoms  usually  pass  into  coma  and  die  within  a 
week.  Such  attacks  are  most  apt  to  arise  in  those  beyond 
middle  life  (see  Gerster  and  Lilienthal,  in  Foster's  Practical 
Therapeutics).  In  some  chronic  cases  the  first  symptoms 
observed  are  moroseness,  bewilderment,  and  irritability,  fol- 
lowed by  depression  with  unsystematized  persecutory  delu- 
sions, delirium,  coma,  and  even  death. 

In  systemic  poisoning  by  iodoform,  stop  the  use  of  the 
drug  and  sustain  the  strength  of  the  patient  while  nature 
is  removing  the  poison. 

Iodoform  sometimes  produces  great  local  irritation  of  the  cu- 
taneous surface,  shown  by  crops  of  vesicles  filled  with  turbid 
yellow  serum  or  even  bloody  serum.  These  vesicles  rupture 
and  expose  a  raw  oozing  surface,  looking  not  unlike  a  burn. 
The  use  of  the  drug  must  be  at  once  abandoned,  for  to  con- 
tinue it  will  not  only  increase  the  dermatitis,  but  will  produce 
constitutional  symptoms.  Wash  the  vesiculated  area  with 
ether  to  remove  iodoform,  open  each  vesicle  and  dress  the 
part  for  several  days  with  gauze  wet  with  normal  salt  solu- 
tion. After  acute  inflammation  ceases  apply  zinc  ointment 
or  cosmolin. 

Europhen  is  a  powder  containing  iodin,  and  the  iodin 
separates  from  it  slowly  when  the  powder  is  applied  to 
wounds  or  ulcers.  It  does  not  produce  toxic  symptoms 
readily,  if  at  all,  and  is  a  valuable  substitute  for  iodoform. 
It  is  used  especially  in  the  treatment  of  ulcers  and  burns. 

Nosophen  is  a  pale  yellow  powder  containing  60  per  cent. 
of  iodin.  Its  bismuth  salt  is  known  as  antinosin.  Nosophen 
is  not  toxic,  is  free  from  odor,  and  is  the  best  of  the  substi- 
tutes for  iodoform. 

Acetanilid  is  frequently  used  as  a  substitute  for  iodoform. 
It  is  of  value  when  applied  to  suppurating,  ulcerating,  or 
sloughing  areas,  but  it  does  not  benefit  tubercular  conditions. 
Sometimes  absorption  takes  place  to  a  sufficient  extent  to 
cause  cyanosis.  If  cyanosis  arises,  stop  the  drug  and  order 
stimulants  by  the  stomach. 

Silver  is  a  valuable  antiseptic.  Halsted  and  Bolton  have 
shown  that  metallic  silver  exerts  an  inhibitive  action  upon 


BACTERIOLOGY.  29 

the  growth  of  micro-organisms  and  does  not  irritate  the  tis- 
sues. Crede  has  demonstrated  the  same  facts.  These  state- 
ments indicate  one  great  reason  why  silver  wire  is  so  useful 
as  a  suture-material.  Halsted  is  accustomed  to  place  silver 
foil  over  wounds  after  the  wounds  have  been  sutured,  and 
Crede  employs  as  a  dressing  a  fabric  in  which  metallic  silver 
is  intimately  incorporated. 

Crede  considers  that  silver  lactate  (actol)  is  an  admirable 
antiseptic.  It  does  not  form  insoluble  albuminates  when  in- 
troduced into  the  tissues  and  is  not  an  irritant.  Silver  citrate 
(itrol)  is  said  to  be  even  a  better  preparation  than  silver  lac- 
tate, and  it  is  a  useful  dusting-powder. 

Formaldehyd  or  formic  aldehyd  has  valuable  antiseptic 
properties.  Formalin  is  a  40  per  cent,  solution  of  the  gas  in 
water.  Solutions  of  this  strength  are  very  irritant  to  the 
tissues,  but  2  per  cent,  solutions  can  be  used  to  disinfect 
wounds.  The  stronger  solutions  are  valuable  for  asepticizing 
chancroids  and  other  ulcers.  The  vapor  of  formalin  is  used 
to  disinfect  wounds,  and  Wood  suggests  its  employment  in 
septic  peritonitis  as  a  means  of  disinfection  after  the  abdomen 
has  been  opened.  A  2  per  cent,  solution  disinfects  instru- 
ments satisfactorily. 

Formalin-gelatin  has  recently  been  introduced  by  Schleich 
as  an  antiseptic  powder.  When  applied  to  a  clean  wound  it 
gives  off  formalin  and  keeps  the  wound  aseptic.  When  it  is 
applied  to  a  sloughing  surface  it  will  not  give  off  formalin 
unless  it  is  mixed  with  pepsin  and  hydrochloric  acid.  The 
commercial  preparation  is  known  as  glutol.  Formalin-gela- 
tin is  used  to  replace  bone-defects. 

Nucleins,  especially  protonuclein,  possess  germicidal 
powers.  Protonuclein  is  of  value  in  treating  areas  of  in- 
fection, particularly  when  sloughing  exists. 

Among  other  antiseptics  of  more  or  less  value  we  may 
mention  trichlorid  of  iodin,  iodol,  chlorid  of  zinc,  chlorid 
of  iron,  loretin,  salol,  oxycyanid  of  mercury,  fluorid  of  so- 
dium, argonin,  sugar,  mustard,  lannaiol,  bichlorid  of  palla- 
dium (in  very  dilute  solution),  thymol,  potash  soap,  iodin, 
salicylic  acid,  boric  acid,  camphor,  eucalyptol,  cinnamon, 
bromin,  chlorin  (as  gas  or  as  chlorin-water),  cinnamic  acid, 
permanganate  of  potassium  or  of  calcium,  chlorate  of  potas- 
sium, alcohol,  and  normal  salt  solution. 

The  best  germicide  is  heat,  and  the  best  form  in  which  to 
apply  heat  is  by  means  of  boiling  water  (even  better  than 
steam).  One  can  use  boiling  water  upon  instruments  and 
dressings,  but  rarely  upon  a  patient  and  never  upon  the  sur- 


30  MODERN  SURGERY. 

geon.  Jeannel,  of  Toulouse,  uses  boiling  salt  solution  in 
abscess-cavities,  and  other  surgeons  employ  steam  or  boiling 
water  to  disinfect  the  medullary  canal  in  osteomyelitis.  Nev- 
ertheless, boiling  water  is  rarely  applied  to  the  patient,  and 
in  many  cases  a  chemical  germicide  must  be  used.  The 
surgeon  should  always  scrub  his  hands  in  a  germicidal  solu- 
tion, and  corrosive  sublimate  is  one  of  the  best  we  possess. 

Distribution. — Microbes  are  very  widely  distributed  in 
nature.  They  are  found  in  all  water  except  that  which  comes 
from  very  deep  springs ;  in  all  soil  to  the  depth  of  3  feet ; 
and  in  air,  except  that  of  the  desert,  that  over  the  open  sea, 
and  that  of  lofty  mountains. 

Microbes  may  be  useful.  Some  of  them  are  scavengers, 
and  clean  the  surface  of  the  earth  of  its  dead  by  the  process 
known  as  "  putrefaction,"  in  which  complex  organic  matter 
is  reduced  to  harmless  gases  and  to  a  mineral  condition. 
The  gases  are  taken  up  from  the  air  by  vegetables,  and  the 
mineral  matter  is  dissolved  in  rain-water  and  passes  into 
the  soil  from  which  it  came,  to  there  again  be  food  for 
plants,  which  plants  will  become  food  for  animals.  Other 
organisms  purify  rivers ;  others  cause  bread  to  rise ;  still 
others  give  rise  to  fermentation  in  liquors.  Microbes  may 
be  harmful.  They  may  poison  rivers  and  soils ;  they  may 
be  parasites  on  vegetable  life ;  they  cause  diseases  of  the 
growing  vine,  and  also  of  wine ;  they  produce  the  mould  on 
stale  damp  bread ;  they  occasionally  form  poisonous  matter 
in  sausages,  in  ice-cream,  and  in  canned  goods ;  and  they 
produce  many  diseases  among  men  and  the  lower  animals. 

With  so  universal  a  distribution  of  these  fungi,  man  must 
constantly  take  them  into  his  organism.  They  are  upon 
the  surface  of  his  body,  he  inhales  them  with  every  breath, 
and  he  swallows  them  with  his  food  and  drink.  Most  of 
them,  fortunately,  are  entirely  harmless ;  others  cannot  act 
on  the  living  tissues  ;  but  some  are  virulent,  and  these  are 
generally  destroyed  by  the  cells  of  the  human  body.  The 
alimentary  canal  always  contains  bacteria  of  putrefaction, 
which  act  only  upon  the  dead  food,  and  not  upon  the  living 
body ;  but  when  man  dies  these  organisms  at  once  attack 
the  tissues,  and  post-mortem  putrefaction  begins  in  the 
abdomen. 

Kocli'S  Circuit. — To  prove  that  a  microbe  is  the  cause 
of  a  disease  it  must  fulfil  Koch's  circuit.  It  must  always  be 
found  associated  with  the  disease ;  it  must  be  capable  of 
forming  pure  cultures  outside  the  body ;  these  cultures  must 
be    capable  of  reproducing  the    disease ;  and  the  microbe 


BACTERIOLOGY.  3 1 

must  again  be  found  associated  with  the  artificially  produced 
morbid  process. 

Disease  -  production. — Disease  -  producing  organisms 
which  enter  the  body  are  usually  rapidly  destroyed.  They 
cannot  dwell  there  long  without  inducing  disease,  but  spores 
can  lie  dormant  in  the  system  for  years,  only  waking  into 
activity  when  they  come  in  contact  with  some  damaged, 
weakened,  or  diseased  part — a  so-called  point  of  least  re- 
sistance (a  loais  iniiioris  i-csistcntice) — which  affords  a  nest 
for  them  to  develop  and  to  multiply,  the  cellular  activities 
of  the  weakened  part  being  unable  to  cope  with  the  activi- 
ties of  the  germs.  Even  large  numbers  of  pathogenic  or- 
ganisms may  induce  no  trouble  in  a  healthy  man  ;  but  let 
them  reach  a  damaged  spot,  and  mischief  is  apt  to  arise. 
Kocher  established  subcutaneous  bone-injuries  in  dogs,  and 
these  injuries  pursued  a  healthy  course  until  the  animal  was 
fed  upon  putrid  meat,  whereupon  suppuration  took  place. 
This  experiment  proves  that  an  organism  can  reach  a  dam- 
aged area  by  means  of  the  blood,  and  it  enables  us  to  under- 
stand how  a  knee-joint  can  suppurate  when  we  merely  break 
up  adhesions,  and  how  osteomyelitis  can  follow  trauma  when 
the  skin  is  intact.  A  given  number  of  organisms  might  pro- 
duce no  effect  on  a  healthy  man,  whereas  the  same  number 
might  produce  disease  in  an  individual  who  was  weak  or  ill- 
nourished,  suffering  from  depression  or  fear,  or  debilitated  by 
the  habitual  use  of  alcohol.  The  personal  increment  plays 
a  great  part  in  disease-production.  Some  individuals  seem 
to  be  immune  to  certain  diseases ;  others  seem  especially 
liable  to  develop  certain  diseases ;  and  these  immunities  and 
liabilities  may  be  hereditary. 

Toxins. — The  action  of  pathogenic  bacteria  upon  the  tis- 
sues is  of  great  importance.  In  the  first  place,  they  abstract 
from  the  blood,  the  lymph,  and  the  cells  certain  elements 
necessary  to  the  body — as  water,  oxygen,  albumins,  carbo- 
hydrates, etc. — and  bring  about  body-wasting  and  exhaustion 
from  want  of  food.  In  the  second  place,  bacteria  produce  a 
vast  number  of  compounds,  some  harmless  and  others  highly 
poisonous.  The  symptoms  of  a  microbic  disease  are  largely 
due  to  the  absorption  of  poisonous  materials  from  the  area 
of  infection.  These  poisons  may  be  formed  from  the  tissues 
by  the  action  upon  them  of  the  bacteria  (toxins  and  pep- 
tones) or  may  be  liberated  from  the  bodies  of  degenerating 
microbes  (bacterial  proteid).  Bacteria  contain  and  secrete 
ferments  like  pepsin  or  trypsin,  and  as  albumoses  are  formed 
in  the  alimentary  canal  by  the  action  of  digestive  ferments 


32 


MODERN  SURGERY. 


upon  proteids,  sugars,  and  starches,  so  microbic  albumoses 
are  formed  by  the  action  of  microbic  ferments  upon  tissues. 
Just  as  the  albumoses  formed  in  digestion  are  poisonous 
when  injected,  so  the  albumoses  of  microbic  action  are  poi- 
sonous when  absorbed.  The  albumoses  of  microbic  action 
are  called  "  toxalbumins."  These  albumoses  often  operate 
as  virulent  poisons  to  the  body-cells. 

A  series  of  compounds  formed  by  the  microbic  destruction 
of  tissue  is  alkaloidal  in  nature.  These  poisonous  alkaloids 
are  readily  diffusible  and,  many  of  them,  very  virulent.  It  is 
probable  that  every  pathogenic  organism  has  its  own  special 
toxin  which  produces  its  characteristic  effects,  although 
the  effects  are  modified  by  the  nature  of  the  soil — that  is  to 
say,  by  the  condition  of  the  tissues.  The  absorption  of  tox- 
ins may  be  very  rapid ;  for  instance,  the  toxins  of  cholera 
may  kill  a  man  before  the  bacillus  has  migrated  from  the 
intestine.  Brieger  uses  the  term  toxin  to  designate  all  of  the 
poisonous  products  of  bacterial  action.  He  divides  toxins 
into  alkaloidal  or  crystallizable  and  amorphous,  the  latter 
being  called  toxalbumins. 

Ptomains. — By  many  writers  the  term  "  ptomain  "  is 
used  to  designate  these  toxins,  but  in  reality  a  ptomain  is 
a  form  of  toxin  that  is  due  to  the  action  of  saprophytic  bac- 
teria. A  ptomain  is  a  putrefactive  alkaloid,  and  a  toxin  is 
any  poison  of  microbic  origin.  Among  these  poisonous  al- 
kaloids may  be  mentioned  tetanin,  typhotoxin,  sepsin,  putres- 
cin,  muscarin,  and  spasmotoxin. 

I/eucomains  must  not  be  confounded  with  the  above- 
mentioned  bodies.  Leucomains  are  alkaloidal  substances 
existing  normally  in  the  tissues,  and  arising  from  physio- 
logical fermentations  or  retrograde  chemical  changes.  They 
are  natural  body-constituents,  in  contrast  to  toxins,  which 
are  morbid.  Leucomams  are  found  in  expired  air,  saliva, 
urine,  feces,  tissues,  and  the  venom  of  serpents.  If  not 
excreted,  these  bodies  may  induce  illness,  and  when  injected 
may  act  as  poisons.  Ordinary  colds  and  some  fevers  result 
from  leucomains  ;  they  play  a  great  part  in  uremia,  and  when 
excretion  is  deficient  the  retained  leucomains  make  the  sys- 
tem a  hospitable  host  for  pathogenic  bacteria.  Among  leu- 
comains may  be  mentioned  adenin,  hypoxanthin,  and  xan- 
thin,  allied  to  uric  acid,  and  other  substances  allied  to  creatin 
and  creatinin. 

Alexins  and  Antitoxins. — Another  group  of  substances 
which  may  arise  from  microbic  action  are  known  as  "  anti- 
toxins."   When  a  person  suffers  from  a  bacterial  malady  the 


BACTERIOLOGY.  33 

toxins  of  the  bacteria,  by  acting  upon  the  body-cells,  cause 
the  body-cells  to  produce  a  product  which  may  kill  the  bac- 
teria (alexin)  or  may  simply  antagonize  the  toxin  (antitoxin) 
These  materials  may  exist  in  blood-scrum  as  leucomains,  or 
may  be  toxins  or  toxalbumins  absorbed  by  the  blood  from  an 
area  of  bacterial  disease.  It  is  a  well-recognized  fact  in  fer- 
mentation that  after  a  time  the  process  ceases,  and  the  addi- 
tion of  more  ferment  is  void  of  result.  The  same  is  true  of 
specific  maladies ;  thus,  if  a  person  recovers,  the  organisms 
disappear,  and  the  injection  of  more  of  them  produces  no 
result ;  in  other  words,  immunity  exists  toward  the  disease. 
This  immunity  was  long  believed  to  arise  from  the  exhaus- 
tion of  some  unknown  constituent  of  tissue  necessary  to  the 
life  of  the  bacteria.  It  is  now  believed  to  be  due  partly  to 
the  capacity  of  the  body-cells  to  destroy  germs,  and  partly 
to  the  production  of  alexins  or  antitoxins,  which,  when  they 
have  developed  in  sufficient  amount,  destroy  the  bacteria  or 
render  bacterial  products  harmless.  In  other  words,  bacteria 
not  only  produce  poisons,  but  also  the  antidotes  for  them. 
Many  observers  are  endeavoring  to  find  the  antitoxin  of 
each  microbic  disease  for  the  purpose  of  applying  it  thera- 
peutically. Great  claims  are  made  as  to  the  value  of  the 
antitoxins  of  diphtheria,  tetanus,  and  suppurations.  Roux 
maintains  that  an  antitoxin  is  not  derived  from  a  toxin, 
but  that  a  toxin  stimulates  the  body-cells  to  secrete  an 
antitoxin.  He  further  shows  that  an  antitoxin  does  not 
destroy  a  toxin,  but  acts  upon  the  body-cells  and  renders 
them  capable  of  withstanding  the  poison.  Buchner  believes 
that  the  reason  the  leukocytes  help  to  ward  off  disease  is 
not  because  they  act  as  phagocytes  to  bacteria,  but  because 
they  furnish  defensive  proteids  (alexins  or  antitoxins). 
Vaughan  and  others  have  proved  that  blood-serum  is  germi- 
cidal ;  that  the  germicidal  agent  is  dissolved  in  the  alkaline 
serum  ;  that  this  agent  is  a  nuclein  which  is  furnished  by  the 
white  cells,  and  this  nuclein  may  be  extracted  and  used 
therapeutically. 

Phagocytes. — The  tendency  of  the  white  blood-cells  and 
of  the  fixed  tissue-cells  to  destroy  organisms  is  undoubted. 
This  process  of  destruction  is  known  as  "  phagocytosis,"  and 
the  destroying  cells  are  called  "  phagocytes."  These  cells  try 
to  eat  up  and  destroy  the  germs.  A  battle-royal  occurs,  the 
microbes  fighting  the  body-cells  with  most  active  ferments ; 
the  body-cells  endeavoring  to  devour  and  destroy  the  bac- 
teria (Fig.  lo).  In  some  cases  the  bacteria  win  absolutely 
and  the  patient  dies.  In  other  cases  they  win  for  a  time  and 
3 


34 


MODERN  SURGERY. 


overwhelm  the  organism,  but  presently  the  body-cells,  whose 
movements  were  inhibited  by  the  poison,  regain  their  ac- 
tivity and  successfully  recur  to  the  attack.  After  the  attack 
is  over  the  body-cells  have  been  educated  to  withstand  this 
poison,  and  new  cells  in  the  future  retain  this  capacity ;  the 
weak  cells  were  killed,  the  fittest  survived,  and  the  descend- 
ant cells  of  the  survivors  are  born  insusceptible.  This  in- 
susceptibility is  called  immunity,  and  lasts  for  a  varying 
period.  Some  persons  seem,  from  birth,  immune  to  certain 
maladies.  The  theory  of  phagocytosis  immunity  assumes 
an  educated  white  corpuscle  and  body-cell.    This  view  origi- 


.«-*^ 


Fig.  io. — Phagocytosis  :  A,  successful ;   B,  unsuccessful  (Senn). 


nated  with  Sternberg,  but  it  is  usually  accredited  to  Metsch- 
nikoff.     Lankester  gave  us  the  term  "  educated  corpuscle." 
Protective    and    Preventive    Inoculations.  —  Our 

knowledge  of  protective  inoculations  for  contagious  dis- 
eases dates  from  Jenner's  discovery  in  1796.  Preventive 
inoculations  with  attenuated  virus  are  due  to  the  experi- 
ments of  Pasteur.  This  observer  discovered  the  cause  of 
chicken-cholera,  and  cultivated  the  micro-organism  of  this 
disease  outside  the  body.  He  found  that  by  keeping  his 
cultures  some  time  they  became  attenuated  in  virulence,  and 
that  these  attenuated  cultures,  inoculated  in  fowls,  caused 
a  mild  attack  of  the  disease,  which  attack  was  protective, 
and  rendered  the  fowl  immune  to  the  most  virulent  cul- 
tures. Cultures  can  be  attenuated  by  keeping  them  for 
some  time,  by  exposing  them  for  a  short  period  to  a  tem- 
perature just  below  that  necessary  to  kill  the  organisms, 
and  by  treating  them  with  certain  antiseptics.  It  has 
further  been  shown  that  injection  of  the  blood-serum  of  an 


BACTERIOLOGY.  35 

animal  rendered  immune  by  inoculation  is  capable  of  making 
a  susceptible  animal  also  immune. 

A  most  important  fact  is  that  animals  may  be  rendered 
immune  to  certain  diseases  by  inoculating  them  with  filtered 
cultures  of  the  microbes  of  the  disease,  the  filtrate  contain- 
ing microbic  products,  but  not  living  microbes.  By  this 
method  animals  can  be  rendered  immune  to  tetanus  and 
diphtheria.  Pasteur's  protective  inoculations  against  hydro- 
phobia owe  their  power  to  microbic  products,  and  Koch's 
lymph  contains  them  as  its  active  ingredients.  The  chief 
feature  in  acquired  immunity  is  the  presence  in  the  blood  and 
tissues  of  elements  which  can  neutralize  the  toxic  products 
or  which  can  kill  bacteria.  These  elements  are  "  antitox- 
ins "  and  "  alexins."  The  present  knowledge  of  them  arose 
from  the  discovery  of  Nuttall  and  Buchner  that  fresh  blood- 
serum  is  germicidal,  the  power  varying  for  different  bacteria 
and  being  limited,  for  a  fixed  amount  of  serum  is  capable  of 
destroying  a  small  dose  of  bacteria  only.  It  has  been  said 
that  in  tetanus  injections  of  the  serum  of  an  immune  animal 
may  cure  the  disease.  The  above  facts  are  of  immense  im- 
portance, for  on  these  lines  may  be  solved  the  problems  of 
the  prevention  and  treatment  of  microbic  maladies. 

Orrhotherapy  or  serum-therapy  is  an  attempt  to  utilize 
therapeutically  the  germicidal  properties  of  blood-serum. 
It  is  believed  that  when  a  man  gets  an  infectious  disease 
the  toxins  act  upon  the  body-cells  and  cause  the  formation 
by  these  cells  of  defensive  proteids,  alexins,  curative  nucleins 
or  antitoxins.  These  products  enable  the  body-cells  to  with- 
stand further  injury  by  the  toxins,  the  disease  comes  to  an 
end,  the  bacteria  die,  and  the  alkaline  blood-serum  is  satu- 
rated with  protective  material.  If  the  above  facts  are  true,  it 
is  an  easy  deduction  that  blood-serum  containing  protective 
material  should  cure  the  disease  if  injected  into  a  patient  suf- 
fering from  an  attack.  Instead  of  using  the  blood-serum 
itself,  some  observers  have  precipitated  the  curative  nuclein 
from  the  serum  and  used  the  nuclein  in  solution  in  fixed 
amounts.  Instead  of  using  the  serum  of  persons  rendered 
immune  by  an  attack  of  the  disease,  many  physicians  have 
employed  the  serum  of  animals  rendered  artificially  immune 
by  injections  of  attenuated  cultures  of  the  bacteria.  Some 
experimenters  have  employed  even  the  serum  of  animals  nat- 
urally immune  to  the  disease.  That  Pasteur  has  devised  a 
method  which  will  usually  prevent  hydrophobia  is  certain 
(p.  182),  and  that  Murri,  of  Bologna,  has  cured  a  case  of 
hydrophobia  seems   proved  (p.    182).     Hosts   of  observers 


36  MODERN  SURGERY. 

believe  in  the  utility  of  tetanus  antitoxin  and  diphtheria 
antitoxin. 

Inconclusive  experiments  have  been  made  in  the  treat- 
ment of  syphilis  by  the  serum  of  dog's  blood,  or  the  blood- 
serum  of  men  laboring  under  tertiary  syphilis ;  in  the  treat- 
ment of  pneumonia  with  the  blood-serum  of  persons  conva- 
lescent from  pneumonia;  and  in  the  treatment  of  sufferers 
from  septic  diseases  with  antistreptococcic  serum — blood- 
serum  of  animals  rendered  immune  to  septic  infections.  Ma- 
lignant tumors  (both  sarcomata  and  carcinomata)  have  been 
treated  with  the  blood-serum  of  dogs,  which  animals  had 
been  injected  with  fluid  expressed  from  malignant  growths 
(Richet  and  Hericourt).  Many  claims  made  for  serum- 
therapy  are  exaggerated,  sensational,  and  unscientific.  That 
there  is  truth  in  the  method  seems  highly  probable,  but  how 
much  of  it  is  true  is  not  yet  definitely  ascertained.  It  is  our 
duty  to  study,  experiment,  and  observe,  and  to  reach  a  con- 
clusion only  after  honest,  careful,  and  thorough  investigation. 
A  little  skepticism  is  as  yet  a  safe  rule. 

Antagonistic  Microbes. — Another  observation  of  im- 
portance is  that  certain  microbes  are  antagonistic  to  one 
another.  The  streptococcus  of  erysipelas  attacks  the  or- 
ganism of  anthrax,  and  is  antagonistic  to  several  infectious 
diseases  (syphilis  and  tuberculosis),  also  to  sarcoma.  We 
should  note  also  that  the  growth  of  some  microbes  affects 
culture-media  favorably  or  otherwise  for  the  growth  of  other 
organisms,  and  the  same  may  be  true  in  the  tissues  of  the 
human  body. 

Mixed  Infection. — A  fact  of  practical  importance  to 
the  surgeon  is  that  an  area  infected  by  one  form  of  patho- 
genic organism  may  be  invaded  by  another  form.  This  is 
known  as  a  mixed  infection,  and  consists  of  a  primary  infec- 
tion with  one  variety  of  organism,  and  a  secondary  infection 
with  another.  Koch  found  both  bacilli  and  micrococci  in 
the  same  lesion  of  tubercle.  A  soil  filled  with  pneumococci 
favors  the  growth  of  pus  cocci  and  tubercle  bacilli.  Tuber- 
culous or  syphilitic  lesions  may  be  attacked  by  erysipelas. 
Chancre  and  chancroid  can  exist  together.  A  syphilitic  ulcer 
is  a  good  culture-soil  for  tubercle  bacilli  (Schnitzler).  Sup- 
puration in  lesions  of  tuberculosis  is  due  to  secondary  infec- 
tion with  pus  organisms. 

Placental  Transmission. — The  direct  transmission  of 
bacteria  from  parent  to  fetus  is  a  problem  still  in  course  of 
solution.  Certain  it  is  that  some  diseases  (as  syphilis)  are 
due  to  the  direct  carrying  of  the  microbes  by  sperm-cell  to 


BACTERIOLOGY. 


37 


germ-cell,  or  to  the  transmission  of  the  micro-organism 
through  the  septum  of  separation  between  the  circulations 
of  the  mother  and  child.  In  many  other  diseases  the  mi- 
crobe is  not  directly  transmitted  (as  in  phthisis),  but  a  patient 
born  with  weakened  tissue-cells  is  prone  to  fall  a  prey  to  the 
latter  malady. 

Special  Surgical  Microbes. — Suppuration  is  caused  by 
microbes.  Can  it  exist  without  them  ?  The  answer  is,  no. 
Injection  of  a  fluid  containing  dead  organisms  will  form  a 
limited  amount  of  pus  ;  injection  of  irritants  forms  a  thin  fluid 
which  may  resemble  pus,  but  which  is  not  pus.  In  surgery 
pus  is  not  met  with  without  the  micro-organisms,  and  the 
presence  of  pus  proves  the  presence  of  micro-organisms. 
Pus  microbes,  or  pyogenic  microbes,  possess  the  property  of 
peptonizing  albumin,  and  thus  forming  pus.  The  peptonizing 
action  is  brought  about  by  bacterial  proteids  or  ferments. 
The  inflammation  which  surrounds  an  area  of  pyogenic  in- 
fection is  caused  by  the  irritant  products  of  bacterial  action 
(toxalbumins,  ammonia,  etc.).  In  the  presence  of  the  pyo- 
genic peptones  inflammatory  exudate  is  unable  to  coagulate. 
The  most  usual  causes  of  suppuration  are  the  following 
micro-organisms : 

StapJiylococc7is  pyogcjics  auretis  (Fig.  1 1),  the  golden-yellow 
coccus.  This  is  the  most  usual  cause  of  abscesses  (circum- 
scribed suppurations);  JJ  per  cent,  of  acute  abscesses  are  due 
to  staphylococci  (W.  Watson  Cheyne).     Staphylococci  are 


Fig.  II.— Staphylococcus    pyogenes  aureus 
in  pus  (X  looo)  (Frankel  and  Pfeiffer). 


Fig.    12. — Streptococcus  pyogenes  in 
pus  (X  lOoo)  (Frankel  and  Pfeiffer). 


found  also  in  osteomyelitis.  The  staphylococcus  pyogenes 
aureus  is  a  facultative  anaerobic  parasite  which  is  widely  dis- 
tributed in  nature,  and  is  found  in  the  soil,  the  dust  of  air, 
water,  the  alimentary  canal,  under  the  nails,  on  and  in  the 
superficial  layers  of  skin,  especially  in  the  axillae  and  peri- 


38  MODERN  SURGERY. 

neum.  It  forms  the  characteristic  color  only  when  it  grows 
in  air.  It  is  killed  in  lO  minutes  by  a  moist  temperature  of 
58°  C,  and  is  instantly  killed  by  boiling  water.  Carbolic  acid 
(i  :  40)  and  corrosive  sublimate  (i  :  2000)  are  quickly  fatal 
to  these  cocci. 

Staphylococcus  pyogenes  albus,  the  white  staphylococcus, 
acts  like  the  aureus,  but  is  more  feeble  in  power.  When  this 
organism  is  found  upon  and  in  the  skin  it  is  called  the 
staphylococcus  epidermidis  albus,  an  organism  which  Welch 
proved  to  be  the  usual  cause  of  stitch-abscesses. 

Staphylococcus  pyogenes  citreus,  the  lemon-yellow  coccus, 
is  found  occasionally  in  acute  circumscribed  suppurations, 
but  far  more  rarely  than  the  other  two  forms.  Its  pyogenic 
power  is  even  weaker  than  that  of  the  albus. 

Staphylococcus  cereus  albus,  found  occasionally  in  acute 
abscesses. 

Staphylococcus  cereus  flavus,  found  occasionally  in  acute 
abscesses. 

Staphylococcus  flavescens,  occasionally  found  in  abscesses. 
Is  intermediate  between  the  aureus  and  albus  (Senn). 

Micrococcus  pyogenes  tenuis  rarely  takes  the  form  of  a 
bunch  of  grapes.  Is  occasionally  found  in  the  pus  of  acute 
abscesses. 

Streptococcus  pyogenes  (Fig.  1 2),  found  in  spreading  suppu- 
rations. Woodhead  tells  us  (Treves'  System  of  Surgery)  that 
six  organisms,  each  of  which  bears  a  separate  name,  are  dis- 
cussed under  this  designation.  Three  of  these  organisms  he 
places  in  one  group,  two  in  another,  and  says  the  sixth  may 
be  a  separate  species. 

1st  Group. — Streptococcus  pyogenes,  found  especially  in 
spreading  suppuration  and  in  very  acute  abscesses.  Cheyne 
says  that  16  per  cent,  of  acute  abscesses  contain  streptococci. 
Is  easily  killed  by  boiUng,  and  can  be  destroyed  by  carbolic 
acid  and  corrosive  sublimate.  Exists  normally  in  nasal  pas- 
sages, vagina,  saliva,  and  urethra. 

Streptococcus  pyogenes  malignus,  an  uncommon  organism 
found  in  splenic  abscess. 

Streptococcus  septicus  has  a  strong  tendency  to  break  up 
into  diplococci. 

2d  Group. — Streptococcjis  of  erysipelas,  found  in  capillary 
lymph-spaces  in  erysipelas.  Many  bacteriologists  believe  it 
to  be  identical  with  the  streptococcus  pyogenes. 

Streptococcus  of  septicemia  and  pyemia.  Most  observers 
maintain  that  it  is  identical  with  the  streptococcus  pyogenes 
and  streptococcus  of  erysipelas. 


BACTERIOLOGY. 


39 


3d  Group. — Streptococcus  articulonon,  found  in  false  mem- 
brane of  diphtheria  (see  the  excellent  article  by  Woodhead  in 
the  System  of  Surgery  by  Frederick  Treves). 

Bacillus  pyogenes  foetidus,  found  especially  in  the  pus  of 
ischiorectal  abscesses. 

Bacillus  pyocyaneus,  found  by  Ernst  in  blue  pus. 

Other  Surgical  Microbes. — Streptococcus  of  erysipelas 
(Fehleisen's  coccus),  as  stated  before,  is  thought  to  be  iden- 
tical with  the  streptococcus 
pyogenes.  Their  difference  in 
action  is  believed  by  Sternberg 
to  be  due  to  difference  in  viru- 
lence induced  by  external  con- 
ditions and  by  the  state  of  the 
tissues  of  the  host.  The  coc- 
cus of  erysipelas  is  somewhat 
larger  than  the  ordinary  form 
of  streptococcus  pyogenes.  In- 
fection takes  place  by  a  wound, 
often  a  very  trivial  wound,  or 
by  the  mucous  membrane.  The 
organism  multiplies  in  the  small 
lymph-channels.  This  organ- 
ism will  cause  puerperal  fever 
in  a  woman  in  childbed  when 
it  gains  access  to  "  an  absorb- 
ing surface  in  the  genital  tract" 
(Senn).  The  streptococcus  may  cause  suppuration  in  ery- 
sipelas, mixed  infection  not  being  necessary  to  cause  pus  to 
form. 

The  gonococcus  (Fig.  14,  the  bacillus  of  Neisser),  the  diplo- 
coccus  which  causes  gonorrhea.  Bumm  proved  that  this  coc- 
cus was  certainly  the  cause  of  the  disease,  by  reproducing  the 
disease  in  a  healthy  female  urethra  by  inoculation  with  the 
twentieth  generation  in  descent  from  a  pure  culture.  Diplo- 
cocci  are  found  often  in  the  secretions  of  apparently  healthy 
mucous  membranes,  and  simulate  very  closely  gonococci. 
Gonococci  cannot  be  cultivated  upon  ordinary  media,  but 
grow  best  upon  human  blood-serum.  In  gonorrhea  the 
organism  is  found  both  inside  and  outside  of  pus-cells  and 
mucus-cells.  It  is  not  certain  that  the  gonococcus  is  pyo- 
genic, the  pus  in  gonorrhea  being  possibly  due  to  mixed 
infection.  Gonococci  stain  easily  and  are  readily  decolorized 
by  Gram's  method. 

Streptococci  are  found  in  noma.     No  specific  organism  has 


Fig.  13. — Anthrax  bacilli  in  blood 

(Vierordt). 


40 


MODERN  SURGERY. 


been  isolated  for  traumatic  spreading  gangrene  or  hospital 
gangrene,  only  pus  cocci  having  been  found. 

The   bacillus  tctani  (Fig.    15,  Nicolaier's  bacillus),  an  an- 
aerobic organism,  found  especially  in  the  soil  of  gardens,  in 


*  ♦  •  •  •!• 


Fig.  14. — Gonococci  from  gonorrheal  pus. 

the  dust  of  old  buildings,  in  street  dirt,  and  in  the  sweepings 
of  stables.  Spores  develop  at  the  ends  of  these  bacilli.  This 
organism  is  capable  of  producing  toxins  of  deadly  power. 
Its  spores  are  hard  to  kill.  The  drug  which  is  most  cer- 
tainly fatal  to  tetanus  bacilH  is  bromin. 

The  bacillus   iuberciilosis  (Fig.    16,  Koch's   bacillus),  the 


Fig.  15. — Bacillus  of  tetanus,  with  spores. 

cause  of  all  tubercular  processes,  is  met  with  especially  in 
dusty  air  which  contains  the  dried  sputum  of  victims  of 
phthisis.  This  infected  air  is  the  chief  means  of  its  trans- 
mission, though  it  may  be  conveyed  by  the  milk  of  tubercu- 


BACTERIOLOGY.  4 1 

lar  COWS  and  the  meat  of  tubercular  animals.  Wounds  may 
open  a  gateway  for  infection. 

Bacillus  anthracis  (Fig.  13),  the  cause  of  malignant  pus- 
tule, or  splenic  fever. 

Bacillus  mallei,  the  cause  of  glanders. 

Bacillus  of  syphilis  (Lustgarten's  bacillus).  That  syphilis 
is  due  to  a  micro-organism  is  highly  probable,  but  that  we 
have  found  the  causative  organism  in  Lustgarten's  bacillus  is 
by  no  means  sure.  A  fact  which  points  strongly  against  it 
as  the  cause  is  that  it  is  found  rather  in  non-contagious  ter- 
tiary lesions  than  in  contagious  secondary^  lesions. 

The  bacillus  coli  communis,  called  also  the  bacterium  coli 
commune  or  the  bacillus   of  Escherich.     Feces  invariably 


^^ 


t 


\  .\   t 


\ 


r  ^,  -     V     \ 


V 


Fig.  16. — Tubercle  bacilli  in  sputum  fZiegler). 

contain  this  organism.  It  is  believed  by  many  observers  to 
be  the  cause  of  appendicitis,  peritonitis,  and  abscesses  about 
the  intestine.  In  cases  of  appendicitis  we  can  rarely  get  a 
pure  culture  of  Escherich's  bacillus,  but  usually  find  also 
streptococci,  staphylococci,  or  pneumococci. 

The  bacillus  of  malignaut  edema  (the  vibrione  septique 
of  Pasteur),  found  especially  in  stagnant  water  and  certain 
varieties  of  soiL 

The  bacillus  of  typhoid  fever  (Eberth's  bacillus)  is  respon- 
sible for  some  cases  of  gangrene,  some  of  embolism,  and 
not  a  few  of  bone  and  joint  disease. 

We  may  mention,  in  conclusion,  as  of  occasional  surgical 
importance,  the  bacillus  of  influenza,  bacillus  of  diphtheria, 
bacillus  of  leprosy,  bacillus  of  rhinoscleroma,  bacillus  of 
fetid  ozena,  bacillus  of  hemorrhagic  septicemia,  bacillus  lac- 
tis  aerogenes  (an  occasional  cause  of  peritonitis). 

Proteus  vulgaris,  or  bacterium  termo,  induces  putrefaction 
and  is  respon.sible  for  many  septic  intoxications. 


42 


MODERN  SURGERY. 


II.  ASEPSIS  AND  ANTISEPSIS. 

Surgical  cleanliness  may  be  obtained  by  either  the  aseptic 
or  the  antiseptic  method.  In  the  aseptic  method  heat, 
chemical  germicides,  or  both  are  used  to  cleanse  the  instru- 
ments, the  field  of  operation,  and  the  hands  of  the  surgeon 
and  his  assistants,  the  surface  being  freed  from  the  chemical 
germicide  by  washing  with  boiled  water  or  with  sahne  solu- 
tion. After  the  incision  has  been  made  no  chemical  germi- 
cide is  used,  the  wound  being  simply  sponged  with  gauze 
sterilized  by  heat ;  if  irrigation  is  necessary,  boiled  water  or 
normal  salt  solution  is  used,  and  the  wound  is  dressed  with 
gauze  which  has  been  rendered  sterile  by  heat.  The  effort 
of  the  surgeon  is  simply  to  prevent  the  entrance  of  micro- 
organisms into  the  tissues.  Some  micro-organisms  must 
enter,  but  the  number  will  be  so  small  that  healthy  tis- 
sues will  destroy  them.  The  aseptic  method  should  be  used 
only  in  non-infected  areas.  If  chemical  germicides  are 
not  used,  the  amount  of  wound-fluid  will  be  small  and  the 
surgeon  can  often  dispense  with  drainage.  If  a  wound  is  to 
be  closed  without  drainage,  every  point  of  bleeding  must  be 
ligated.  It  is  often  advisable  to  sew  up  the  wound  with 
Halsted's  subcuticular  stitch  (Fig.  17).     If  this  stitch  is  em- 


FiG.  17. — Halsted's  subcuticular  suture. 

ployed,  the  skin  staphylococcus  does  not  obtain  access  ta 
stitch-holes  and  stitch-abscesses  cannot  arise.  This  suture 
may  consist  of  catgut,  silk,  or,  preferably,  silver  wire,  this  lat- 
ter agent  being  capable  of  certain  sterilization  by  heat  and 
exercising  a  powerful  inhibitory  action  on  micro-organisms. 
If  a  wound  is  closed  without  drainage,  firm  compression  is 
applied  over  the  wound  to  obliterate  any  cavity  which  may 
exist  In  some  regions  of  the  body  wounds  are  sealed  with 
collodion  or  iodoform-collodion.  If  irrigation  is  not  prac- 
tised and  the  wound  is  dressed  with  dry  gauze,  the  pro- 
cedure is  said  to  be  by  the  "  dry  "  aseptic  method.  In  the 
antiseptic  method  the  same  preparations  are  made  for  the 
operation  as  in  the  aseptic  method,  but  during  the  operation 
sponges  impregnated  with  a  chemical  germicide  are  used. 


ASEPSIS  AND  ANTISEPSIS.  43 

and  the  wound  is  dressed  with  gauze  containing  corrosive 
sublimate  or  some  other  chemical  germicide.  If  the  wound 
is  not  flushed  with  a  chemical  germicide,  and  is  dressed  with 
dry  gauze,  the  operation  is  said  to  be  by  the  "  dr>^  "  antisep- 
tic method.  The  antiseptic  method  is  preferred  in  infected 
areas.  Dry  dressings  are  usually  preferable  to  moist  dress- 
ings, because  they  are  more  absorbent  and  do  not  act  as 
poultices,  and  dry  dressings  may  be  used  even  when  the 
wound  has  been  flushed.  Year  by  year  the  aseptic  method 
becomes  more  popular.  Surgeons  have  learned  that  the 
most  important  factor  in  asepsis  is  mechanical  cleansing  by 
means  of  soap  and  water.  The  chemical  germicide  plays  a 
secondary  rather  than  a  vital  part.  In  many  regions  a  strong 
chemical  germicide  must  not  be  used  (in  the  abdomen,  in  the 
brain,  in  joints,  in  the  pleural  sac,  and  in  the  bladder),  and  in 
other  regions  (mucous  surfaces  and  fatty  tissue)  it  is  produc- 
tive of  harm  rather  than  good. 

Preparations  for  an  Operation. — The  surgeon  and  his 
assistants  remove  their  coats,  roll  up  their  sleeves,  and 
envelop  their  bodies  in  aseptic  or  antiseptic  sheets  to  pro- 
tect the  patient  and  themselves.  The  hands  and  forearms 
are  scrubbed  with  soap  and  hot  sterile  water.  There  is 
nothing  equal  to  the  ethereal  soap  of  Johnston,  which  is  a 
solution  of  castile  soap  in  ether.  Green  soap  or  castile  soap 
can  be  used.  The  brush  employed  is  kept  constantly  in  a 
I  :  1000  solution  of  corrosive  sublimate.  The  nails  are  cut 
short,  are  cleansed  with  a  knife,  and  the  hands  are  again 
scrubbed.  The  hands  are  dipped  in  a  hot  solution  of  cor- 
rosive sublimate,  and  with  the  forearms  are  scrubbed  for  at 
least  a  minute,  the  nails  receiving  especial  care ;  they  are 
then  dipped  for  one  minute  into  pure  alcohol  and  are  again 
bathed  with  the  mercurial  solution.  Kelly  disinfects  the  hands 
by  washing  them  with  soap  and  water,  dipping  them  in  a  so- 
lution of  permanganate  of  potassium  (a  saturated  solution  in 
distilled  water),  and  decolorizing  them  in  a  saturated  solution 
of  oxalic  acid  and  washing  off  the  oxalic  acid  in  sterile  water. 

Weir  has  highly  commended  the  following  plan  and  Stim- 
son  is  also  pleased  with  it.  Scrub  the  hands  with  a  brush 
and  green  soap  and  in  running  hot  water.  Clean  under  the 
nails  with  a  piece  of  soft  wood.  Place  about  a  tablespoonful 
of  chlorinated  lime  in  the  palm  of  the  hand,  place  upon  the 
lime  an  equal  amount  of  washing-soda,  add  a  little  water, 
and  rub  the  creamy  mixture  over  the  arms  and  hands  until 
the  rough  granules  of  sodium  carbonate  are  no  longer  felt. 
Place  the  paste  under  and  around  the  nails  by  means  of  a 


44 


MODERN  SURGERY. 


bit  of  sterile  orange  wood.  Wash  off  the  arms  and  hands 
in  hot  sterile  water.' 

Instruments  are  disinfected  by  boiling  for  fifteen  minutes 
in  a  I  per  cent,  solution  of  carbonate  of  sodium  and  then 
rinsing  them  in  a  5  per  cent,  solution  of  carbolic  acid.  The 
carbonate  of  sodium  prevents  rusting.  Boiling  unfortunately 
destroys  to  some  extent  the  keenness  of  the  cutting  instru- 
ments. They  are  kept  in  trays  containing  boiled  water.  In- 
struments can  be  disinfected  satisfactorily  by  keeping  them 
for  fifteen  minutes  in  a  5  per  cent,  solution  of  carboHc  acid. 
Instruments  with  handles  of  wood  must  not  be  boiled.  If 
such  instruments  are  used,  they  can  be  disinfected  by  the  use 
of  carbolic  acid,  but  they  should  not  be  used.  After  the 
completion  of  the  operation  the  instruments  should  be 
scrubbed  with  soap  and  water,  boiled,  and  dried.  Marine 
sponges  are  rarely  used,  small  pieces  of  sterilized  or  anti- 
septic gauze  being  preferred.  In  the  abdomen  Ashton's 
aseptic  gauze  pads  are  employed.  These  pads  are  about 
ten  inches  square,  and  are  made  of  a  number  of  folds  of 
gauze  stitched  loosely  at  the  edges. 

Whenever  possible,  give  the  patient  some  days'  rest  in 
bed  before  a  severe  operation,  and  place  him  on  a  diet  nutri- 
tious but  not  bulky.  The  night  before  the  operation  give  a 
saline  cathartic,  and  the  morning  of  the  operation  employ 
an  enema.  Emptying  the  bowels  lessens  the  danger  of 
sepsis  after  operation.  It  is  desirable  that  the  rectum  be 
empty,  because  in  shock  the  stomach  cannot  absorb,  and  we 
may  wish  to  utilize  the  absorbing  power  of  the  rectum  and 
give  stimulants  by  enema.  Whenever  possible,  give  a  gen- 
eral warm  bath  the  day  before.  The  evening  before  the 
operation  scrub  the  entire  field  of  operation,  and  well  clear 
of  it,  with  soap  and  water ;  shave  if  necessary ;  wash  with 
ether ;  scrub  well  with  hot  corrosive-sublimate  solution 
(i  :  1000);  apply  a  layer  of  moist  corrosive-sublimate  gauze, 
and  place  over  this  dry  antiseptic  gauze,  a  rubber  dam,  and 
a  bandage.  On  removing  the  dressings  to  perform  the  opera- 
tion cleanse  the  part  again  exactly  as  before.  In  emergency 
cases  disinfection  can  only  be  practised  just  previous  to  the 
operation.  Disinfection  can  be  thoroughly  effected  by  the 
use  of  chlorinated  lime  (Weir,  Stimson).  Surround  the  field 
of  operation  with  dry  sterile  sheets. 

To  clean  the  vagina  or  rectum,  use  a  sponge  soaked 
with  creolin  and  Johnston's  ethereal  soap  (i  :  16),  and  subse- 
quently irrigate  with  hot  saline  fluid  or  boric  acid  solution. 

'  Medical  Record,  April  3,  1897. 


ASEPSIS  AND  ANTISEPSIS.  45 

To  clean  the  mouth  scrub  the  teeth  with  a  brush  and  castile 
soap  twice  a  da}'  and  rinse  out  the  mouth  with  peroxide  of 
hydrogen,  or  a  solution  of  boracic  acid  every  three  hours 
for  several  days. 

Irrig-ation  is  often  practised  in  septic  wounds,  but  is  not 
required  in  aseptic  wounds.  Among  irrigating  fluids  we  may 
mention  corrosive  sublimate,  carbolic  acid,  peroxid  of  hydro- 
gen, boric  acid  solution,  and  normal  salt  solution.  Hot 
normal  salt  solution  is  the  best  agent  with  which  to  irrigate 
the  peritoneal  cavit}-,  the  pleural  sac,  the  interior  of  joints, 
and  the  surface  of  the  brain.  This  solution  contains  0.7  per 
cent,  of  sodium  chloride. 

Many  surgeons  employ  Landerer's  dry  method  in  ope- 
rating aseptically.  No  fluid  is  applied  to  the  wound.  As 
the  wound  is  enlarged  gauze  sponges  are  packed  in  to  arrest 
hemorrhage.  On  the  completion  of  the  operation  the  sponges 
are  removed,  any  bleeding  points  are  ligated,  and  the  wound 
is  closed  without  drainage. 

The  favorite  ligature-material  is  catgut,  which  is  well  pre- 
pared by  boiling  in  alcohol.  Another  method  is  to  take  raw 
catgut,  keep  it  in  ether  for  twenty-four  hours,  soak  it  for  twenty- 
four  hours  in  an  alcoholic  solution  of  corrosive  sublimate 
(i  :  500),  wind  it  on  sterilized  glass  rods,  and  place  it  for  keep- 
ing in  ether  or  in  alcohol.  Fowler's  catgut  is  prepared  by 
boiling  in  alcohol,  and  is  carried  in  hermetically  sealed  glass 
tubes  containing  alcohol,  each  tube  holding  twelve  ligatures. 
Johnston's  quick  method  of  preparing  catgut  is  as  follows  : 
place  it  for  twenty-four  hours  in  ether ;  at  the  end  of  this 
period  place  it  in  a  solution  containing  20  grains  of  corro- 
sive sublimate,  100  grains  of  tartaric  acid,  and  6  ounces  of 
alcohol.  The  small  gut  is  kept  in  this  for  ten  or  fifteen 
minutes,  the  larger  gut  from  twenty  to  thirty  minutes,  but 
never  longer.  It  is  placed  for  keeping  in  a  mixture  contain- 
ing I  drop  of  chlorid  of  palladium  to  8  ounces  of  alcohol. 
This  gut  is  strong  and  reliable.  At  the  time  of  operation  the 
gut  is  placed  in  a  solution  one-third  of  which  is  5  per  cent, 
carbolic-acid  solution  and  two-thirds  of  which  are  alcohol. 
Chromicized  gut  will  not  be  absorbed  so  readily  as  other 
gut.  It  is  prepared  by  adding  200  parts  by  weight  of  cat- 
gut to  200  parts  of  carbolic  acid,  2000  parts  of  water,  and  i 
part  of  chromic  acid.  After  remaining  in  this  solution 
twenty-four  hours  it  is  transferred  for  permanent  keeping  to 
ether  or  to  alcohol.  Kelly  and  Clark  prepare  catgut  by  boil- 
ing it  in  cumol.  Senn  uses  gut  prepared  with  formalin.  The 
great  advantage  of  formalin  gut  is  that  it  can  be  boiled  with- 


46  MODERN  SURGERY. 

out  injury.  Silk  can  be  used  for  both  ligatures  and  sutures ; 
many  sizes  should  be  kept  on  hand.  Sutures  of  silk  should 
be  well  boiled  before  using.  A  convenient  method  of  prepa- 
ration is  to  wind  the  silk  on  a  glass  spool,  place  the  spool  in 
a  large  test-tube,  close  the  mouth  of  the  tube  with  jeweller's 
cotton,  introduce  the  tube  into  a  steam  sterilizer,  and  keep  it 
there  for  one  hour.  These  tubes  are  carried  in  wooden  boxes 
sealed  with  rubber  corks.  Silkworm  gut  contains  fewer  bac- 
teria than  catgut  and  does  not  swell  when  introduced  into  a 
wound.  It  is  a  very  valuable  suture-material,  but  is  not  used 
for  ligatures.  Silkworm  gut  is  prepared  by  placing  it  in 
ether  for  forty-eight  hours  and  in  a  solution  of  corrosive 
sublimate  (i  :  looo)  for  one  hour.  It  is  carried  in  a  long 
tube  filled  with  alcohol.  A  few  minutes  before  using  the 
gut  is  placed  in  carbolic  acid  and  alcohol  (one-third  of  a  5 
per  cent,  solution  of  acid,  two-thirds  of  alcohol).  Silk  and 
catgut  should  be  tied  by  the  reef-knot.  Silkworm  gut  is  tied 
by  the  surgeon's  knot.  The  first  double  knot  is  double  and 
tight,  the  second  is  single  and  is  lightly  tied.  If  the  second 
knot  is  light,  it  will  not  cut  (Greig  Smith).  Silver  wire  is 
prepared  by  boiling. 

Most  wounds  are  closed  by  interrupted  sutures  of  silk- 
worm gut,  but  silk,  catgut,  chromic  catgut,  or  silver  wire  can 
be  used.  The  old  continuous  suture  (Glover's  stitch)  is  rarely 
used.  An  admirable  closure  can  be  effected  by  Halsted's 
subcuticular  stitch,  and  scarcely  any  scar  results.  Marcy's 
buried  tendon  sutures  are  very  valuable,  especially  in  hernia 
operations  and  in  various  operations  upon  the  abdomen. 
Kangaroo  tendon  is  the  best  material  for  buried  sutures. 
This  tendon  is  prepared  by  boiling  it  for  one  hour  in  alcohol 
and  then  treating  it  by  the  palladium  process  exactly  as  cat- 
gut is  treated. 

Dressings  are  made  of  cheese-cloth.  This  material  is 
boiled  in  a  solution  of  carbonate  of  sodium,  rinsed  out,  and 
dried ;  it  is  then  soaked  for  twenty-four  hours  in  a  solution 
containing  i  part  of  corrosive  sublimate,  2  parts  of  table-salt, 
and  500  parts  of  water.  It  is  placed  in  jars,  and  it  may  be 
kept  moist  or  dry. 

Sterilized  gauze  is  prepared  by  boiling  the  material  in 
soda,  rinsing,  and  either  boiling  it  for  fifteen  minutes  or 
placing  it  in  the  steam  sterilizer  for  the  same  time. 

Iodoform  gauze  is  useful  for  packing  and  for  dressing  foul 
wounds.  It  is  prepared  as  follows  :  make  an  emulsion  com- 
posed of  equal  quantities  by  weight  of  iodoform,  glycerin, 
and  alcohol,  and  add  corrosive  sublimate  in  the  proportion 


ASEPSIS  AND   ANTISEPSIS.  47 

of  I  part  to  the  1000  of  the  mixture.  This  mixture  stands 
for  three  days.  Take  moist  bichlorid  gauze,  .saturate  it 
with  the  emulsion,  let  it  drip  for  a  time,  and  keep  it  in  ster- 
ilized and  covered  glass  jars  (Johnston).  Lister's  cyanid 
gauze  (double  cyanid  of  zinc  and  mercury)  is  not  certainly 
antiseptic,  and  must  be  dipped  into  a  corrosive-sublimate  so- 
lution (i  :  2000)  before  using.  All  forms  of  gauze  can  be 
bought  ready  prepared  from  reliable  firms.  Some  surgeons 
place  silver  foil  upon  a  wound  before  applying  the  gauze 
(Halsted,  p.  29).  Small  wounds  in  which  drainage  is  not 
employed  may  often  be  dressed  by  laying  a  film  of  aseptic 
absorbent  cotton  over  the  wound  and  applying,  by  means 
of  a  clean  camel's-hair  brush,  iodoform  collodion  (grs.  xlviij 

to  3j). 

When  a  wound  is  dressed  with  gauze  a  rubber-dam  is 
sometimes  laid  over  the  dressings,  so  as  to  diffuse  the  dis- 
charge and  prevent  it  from  coming  rapidly  to  the  surface. 
The  use  of  the  rubber-dam  is  not  nearly  so  common  as  for- 
merly. In  an  aseptic  wound  dry  dressing  uncovered  by  rub- 
ber is  the  most  useful.  When  a  dressing  is  covered  by  an 
impermeable  material  it  becomes  wet,  acts  as  a  poultice,  and 
the  discharges  on  the  dressing  may  undergo  decomposition. 
Drainage  is  obtained  when  needed  by  rubber  or  glass  tubes, 
by  strands  of  horsehair,  silkworm  gut,  or  catgut,  or  by  pieces 
of  gauze.  Gauze,  catgut,  etc.,  are  known  as  capillary  drains. 
When  moist  they  drain  serum  excellently,  but  pus  very 
badly,  or  not  at  all.  Drainage-tubes  or  strands  are  brought 
out  at  a  portion  of  the  wound  which  will  be  dependent  when 
the  patient  is  recumbent.  Drainage  is  used  in  all  infected 
wounds,  in  most  very  large  wounds,  in  wounds  to  which  irri- 
tant antiseptics  have  been  applied,  and  in  cases  in  which  large 
abnormal  cavities  exist.  Dressings  must  be  changed  as  soon 
as  soaking  is  apparent,  and  the  change  must  be  effected  with 
all  of  the  aseptic  care  employed  in  the  operation.  Stitches 
may  usually  come  out  about  the  sixth  day.  In  large 
wounds  only  a  iQw  of  them  are  taken  out  at  one  time,  the 
remainder  being  allowed  to  remain  for  a  couple  of  days 
longer.  When  a  stitch  begins  to  cut  it  is  doing  no  good, 
and  it  should  be  removed,  no  matter  how  short  a  time  it  has 
been  in  place. 

Preparation  of  Marine  Sponges. — Beat  out  the  dust ; 
place  them  for  forty-eight  hours  in  a  solution  of  hydro- 
chloric acid  (15  per  cent.) ;  wash  them  out  with  water  ;'  place 
them  for  one  hour  in  a  solution  of  permanganate  of  potas- 
sium (siij  to  5  pints  of  water) ;  soak  for  four  hours  in  a  solu- 


48  MODERN  SURGERY. 

tion  containing  lo  ounces  of  hyposulphite  of  sodium,  5 
ounces  of  hydrochloric  acid,  and  3  pints  of  water ;  wash 
with  running  water  for  six  hours.  Keep  the  sponges  in  a 
jar  containing  corrosive-subHmate  solution  (i  :  1000).  After 
using,  wash  in  hot  water,  soak  for  half  an  hour  in  a  solution 
of  sodium  carbonate  (i  :  32),  wash  in  hot  water,  and  replace 
in  corrosive  sublimate.  A  marine  sponge  inevitably  becomes 
foul  in  its  interior,  and  should  not  be  used. 

Senn's  Decalcified  Bone-chips. — Take  the  shaft  of  the 
tibia  or  femur  of  a  recently  killed  ox,  saw  it  into  portions 
two  inches  in  length,  remove  the  marrow  and  periosteum, 
and  place  the  fragments  of  bone  in  a  15  per  cent,  solution 
of  hydrochloric  acid.  Change  the  solution  every  twenty- 
four  hours.  In  from  two  to  four  weeks  the  bone  will  be 
decalcified.  Wash  in  distilled  water,  place  the  pieces  of  de- 
calcified bone  for  a  few  minutes  in  a  dilute  solution  of  potash 
to  neutrahze  the  acid,  and  then  immerse  for  twenty-four 
hours  in  distilled  water.  The  portions  of  bone  are  cut  into 
strips  in  the  direction  of  the  long  axis  of  the  segments. 
Each  strip  is  three-quarters  of  an  inch  wide  and  should  be 
sliced  into  bits  one  millimeter  thick.  These  chips  are  kept 
in  an  alcoholic  solution  of  corrosive  sublimate  (i  :  500). 

III.    INFLAMMATION. 

Definition. — Inflammation  is  a  nutritive  disturbance  aris- 
ing from  tissue-damage,  and  is  not  an  increase  of  nutrition. 
It  is  defined  by  Sanderson  as  "the  succession  of  changes 
which  occur  in  a  living  tissue  when  it  is  injured,  provided 
that  the  injury  is  not  of  such  a  degree  as  at  once  to  destroy 
its  structure  and  vitality."  The  changes  alluded  to  in  this 
definition  comprise — (i)  changes  in  the  vessels  and  the  cir- 
culation ;  (2)  departure  of  fluids  and  solids  from  the  vessels ; 
and  (3)  changes  in  the  perivascular  tissues. 

Vascular  and  circulatory  changes  are  essential  to  in- 
flammation in  both  vascular  and  non-vascular  tissues.  In 
the  former  they  occur  in  the  inflamed  tissues ;  in  the  latter 
(cornea  and  cartilage)  they  are  manifest  in  neighboring  tis- 
sues from  which  the  non-vascular  area  derives  its  nutritive 
material. 

Active  Hyperemia. — When  an  irritant  is  applied  to 
tissue  there  may  be  a  momentary  arterial  contraction  due 
to  irritation  of  the  nerves,  but  this  contraction  is  transitory, 
and  is  not  an  inflammatory  phenomenon.  The  first  vascu- 
lar phenomenon  is  dilatation  of  all  the  vessels — capillaries,, 


INFLAMMA  TION. 


49 


venules,  and  arterioles — appearing  first  and  being  most  pro- 
nounced in  the  small  arteries.  As  a  result  of  the  dilatation 
there  are  increased  rapidity  of  circulation  and  increased  deter- 
mination of  blood  to  the  part,  and  the  area  of  hyperemia 
becomes  warmer  than  is  normal.  This  condition  of  in- 
creased circulatory  activity  is  known  as  "  active  hyperemia  " 
(Fig.  19). 

Active  hyperemia  is  an  increase  in  the  amount  of  moving 
blood  in  a  part.  Passive  hyperemia  is  an  increase  in  the 
amount  of  blood  in  a  part, 
but  not  of  moving  blood,  as 
passive  hyperemia  or  con- 
gestion is  due  to  venous  ob- 
struction, and  the  blood  is 
stagnated.  Plethora  means 
an  increase  in  the  total 
amount  of  body  blood. 
Diminution  in  the  amount  of 
blood  in  a  part  is  ischemia. 

In  active  hyperemia  more 
blood  goes  to  the  part  and 
more  blood  passes  through 
it,  an  increased  amount  of 
venous  blood  comes  from 
the  hyperemic  area,  the 
venous  tension  is  increased, 
and  the  veins  may  even  pul- 
sate. The  capillaries,  which 
under  ordinary  circum- 
stances contain  but  few 
blood-cells  (Fig.  18),  become  filled  with  corpuscles,  and  even 
the  smallest  capillaries  pulsate.  The  capillaries  contain  no 
muscle-fiber,  and  hence  these  tubes  cannot  actively  contract, 
contraction  or  dilatation  depending  upon  the  amount  of  blood 
sent  to  or  retained  in  them.  In  active  hyperemia  the  in- 
creased amount  of  blood  sent  to  the  part  causes  capillary  di- 
latation. Fluid  elements  rarely  leave  the  blood-vessels  dur- 
ing active  hyperemia,  but  they  occasionally  do.  The  wheals 
of  urticaria  are  thus  formed  (Warren).  Active  hyperemia  is 
often  the  first  stage  of  an  inflammation,  but  it  is  not  of  neces- 
sity followed  by  other  inflammatory  changes,  and  it  can  be 
caused  by  nerve-section  or  nerve-stimulation. 

During  active  hyperemia  the  capillaries  are  crowded  with 
corpuscles  and  the  blood  in  the  veins  is  of  a  much  brighter 
red  than  in  health.     The  red  blood-cells  are  swept  along  the 
4 


Fig.  18. — Normal  vessels  and  blood-stream. 


so 


MODERN  SURGERY. 


-centre  of  the  current  (in  the  axial  stream);  the  white  blood- 
cells  float  lazily  along  near  the  vessel-wall  (Fig.  19). 

Retardation. — After  active  hyperemia  has  existed  for  a 
variable  time  the  blood-current  begins  to  lessen  in  velocity, 
until  it  becomes  more  tardy  than  in  health.  This  is  known 
as  "  retardation  of  the  circulation."  Retardation  is  first  noted 
in  the  venules,  next  in  the  capillaries,  and  last  in  the  arteri- 
oles ;  but  arterial  pulsation  continues.  The  white  cells  show 
a  strong  tendency  to  adhere  to  the  vein-walls,  and,  as  a  re- 
sult, accumulate  against 
the  inside  of,  and  stick 
to,  these  walls  and  to  one 
another,  until  the  veins 
are  entirely  lined  with 
layers  of  leukocytes.  In 
the  capillaries  some  leu- 
kocytes gather,  but  not 
many.  In  the  arteries 
they  adhere  during  car- 
diac dilatation,  but  are 
swept  away  by  the  force 
of  the  heart's  contraction. 
Retardation  is  believed  to 
be  chiefly  due  to  paresis 
of  the  muscular  walls  of 
the  arterioles.  This 
causation  seems  probable 
when  we  recall  Lord  Lis- 
ter's experiments  upon 
the  pigment-cells  of  the 
frog's  foot.  Lister  proved  that  inflammation  paralyzes  the 
pigment-cells,  and  concluded  that  dilatation  at  the  focus  of 
an  inflammation  is  due  to  the  paralyzing  action  of  an  irritant. 
Dilatation  at  a  distance  from  the  focus  is  a  reflex  phenomenon 
(W.  Watson  Cheyne). 

Oscillation  and  Stagnation. — By  this  accumulation  of 
leukocytes  the  blood-stream  is  progressively  narrowed  and 
the  axial  current  is  impeded.  The  red  blood-cells  begin  to 
stick  to  one  another,  forming  aggregations  like  rouleaux  of 
coin,  which  increase  the  difficulty  the  axial  current  has  to 
contend  with,  until  progressive  movement  ceases  and  the 
contents  of  the  vessels  sway  to  and  fro  with  the  heart-beat. 
This  is  the  stage  of  oscillation.  In  a  short  time  oscillation 
ceases  and  the  vessels  are  filled  with  blood  which  does  not 
move,   and  the  vessel-walls  become  irregular  in  outline  or 


Fig,  19. — Dilatation  of  the  vessels  in  inflammation. 


IXFLAMMA  T/OiV. 


51 


even  pouched.  This  is  known  as  "  stasis  "  or  "  stagnation  " 
(Fig.  20).  If  stasis  persists,  coagulation  or  thrombosis  oc- 
curs, because  the  vessel-walls  hav^e  been  so  injured  by  the 
irritant  as  to  be  practically  dead  material,  and  they  are  no 
longer  able  to  prevent 
clotting  of  their  contents.  -^^ 
Stasis  is  chiefly  due  to 
paralysis  and  damage  of 
the  vessel-walls.  We  can 
then  sum  up  the  vascular 
changes  of  inflammation 
by  stating  that  they  con- 
sist in  a  dilatation  of  the 
vessel-walls,  in  a  primary 
acceleration,  a  secondary 
retardation,  and  a  subse- 
quent stagnation  of  the 
blood-current  with  adhe- 
sion of  leukocytes  to  the 
walls  of  veins  and  capil- 
laries, and  the  aggrega- 
tion into  masses  of  the 
red  blood-cells.  If  stasis 
persists,  the  vessel-walls 
become  profoundly  in- 
volved in  the  inflam- 
matoiy  change,  and  they  may  rupture  or  be  completely  de- 
stroyed. 

Bxudation  of  Fluids. — It  is  to  be  remembered  that  in 
the  process  of  nutrition  serum  and  even  white  cells  pass  into 
the  tissues  through  the  walls  of  veins  and  capillaries.  In  in- 
flammation the  same  thing  happens,  but  the  exudation  is 
vastly  greater  in  amount  and  is  different  in  composition.  In 
a  slight  inflammation,  and  in  the  early  stage  of  any  inflam- 
mation, there  is  an  increase  in  the  fluid  exudate,  and  we 
speak  of  the  condition  as  "  serous  inflammation."  This  fluid 
is  really  not  serum,  but  is  liquor  sanguinis.  We  find  true 
serum  in  passive  congestion,  not  in  active  inflammation. 
The  fluid  in  a  serous  exudation  contains  very  few  white 
cells,  and  hence  little  or  no  fibrin  can  form  in  it,  and  coagu- 
lation does  not  take  place ;  and  if  the  inflammation  goes  no 
further,  it  is  absorbed  by  the  lymphatics.  A  blister  is  an 
example  of  serous  inflammation.  If  the  inflammation  con- 
tinues to  intensify,  the  exudation  is  altered  in  character — it 
becomes  thicker,  turbid,  and  very  coagulable.     It  contains 


Fig.  2o. — Stasis  of  blood  and  diapedesis  of  white 
corpuscles  in  inflammation. 


5^ 


MODERN  SURGERY. 


white  cells  and  fibrin-elements,  and  coagulates  in  the  tissues. 
This  fluid  is  known  as  "  lymph  "  or  plastic  exudation,  and 
when  it  is  present  we  speak  of  the  condition  as  "  plastic  in- 
flammation." The  lymphatics  endeavor  to  absorb  the  fluid, 
but  become  occluded  by  coagulation,  and  the  area  they 
drain  becomes  swollen,  hard,  and  "  brawny."  Lymph  can  be 
seen  in  the  anterior  chamber  of  the  eye  in  cases  of  plastic 
iritis.  The  slighter  the  inflammation  the  less  albuminous  is 
the  fluid — the  higher  the  inflammation  the  more  albuminous 
is  the  fluid.  The  focus  of  an  inflammation  feels  brawny  be- 
cause of  coagulation  of  a  highly  albuminous  exudate — the 
periphery  of  an  inflammation  is  soft  and  edematous  because 
of  the  presence  there  of  thin  and  non-coagulable  exudate. 

Diapedesis  or  Migration. — Even  early  in  an  inflamma- 
tion some  few  white  corpuscles  pass  through  the  vessel-walls  ; 


Fig. 


-Stages  of  the  migration  of  a  single  white  blood-corpuscle  through  the  wall  of  a  vein 
(Caton). 


but  when  the  inflammation  is  well  established  large  numbers, 
and  when  it  is  severe  vast  hordes,  pass  into  the  perivascular 
tissues.  This  process  is  known  as  "  diapedesis  "  or  "  migra- 
tion." The  leukocytes  throw  out  protoplasmic  arms,  insert 
themselves  between  the  cells  of  the  walls  of  the  vessel,  and 
pull  themselves  through  by  their  power  of  ameboid  move- 
ment. They  do  not  pass  through  existing  open  doors,  but 
form  openings  which  close  after  them.  This  is  readily  ac- 
complished, because  the  vessel-wall  is  itself  damaged,  weak- 
ened, and  convoluted.  The  escape  of  leukocytes  takes  place 
chiefly  from  the  venules,  though  some  migrate  through  the 
capillaries  and  even  the  arterioles  (Fig.  21). 

In  very  acute  inflammation  the  vessel-walls  are  so  dam- 
aged that  red  corpuscles  also  escape,  making  the  tissue  ap- 


INFLAMMATION.  53 

pear  as  if  infiltrated  with  blood.  The  white  corpuscles  often 
greatly  increase  in  number  in  the  blood  of  a  person  who  has 
an  acute  inflammation  (leukocytosis),  and  the  blood-making 
organs,  such  as  the  spleen  and  lymphatic  glands,  are  often 
enlarged.  The  blood-plaques  or  third  corpuscles  are  found 
to  be  present  in  increased  numbers.  These  blood-plaques 
are  not  seen  in  moving  blood,  but  are  found  in  blood-clot, 
their  usual  proportion  to  red  cells  being  as  i  to  20,  and  they 
are  especially  numerous  at  the  height  of  fever-processes  and 
during  convalescence  from  an  extensive  abscess. 

Changes  in  the  Perivascular  Tissues. — The  exuded 
liquor  sanguinis  coagulates,  and  as  a  result  of  the  exudation 
of  elements  of  the  blood  the  tissues  are  softened,  separated, 
and  overfed.  The  abundance  of  food  causes  tissue-cells  to 
multiply,  and  this  process  is  known  as  "  cell-proliferation." 
To  the  proliferating  cells  of  the  perivascular  tissues  are  added 
the  migrated  leukocytes,  the  individual  tissue-elements  are 
separated  and  their  identity  is  destroyed,  and  a  mass  is  formed 
consisting  of  small  round  or  oval  cells  held  together  by  ge- 
latinous intercellular  material.  The  newly  formed  cellular 
mass  is  called  "  embryonic  tissue,"  inflammatory  new  forma- 
tion, indifferent  tissue,  juvenile  tissue,  or  plastic  infiltration. 
The  tissues  have  reverted  to  a  condition  identical  with  the 
tissues  of  the  embryo,  as  the  first  step  in  repair.  Embryonic 
tissue  may  be  absorbed  by  the  lymphatics.  It  may  be  con- 
verted into  pus  if  infected  with  pyogenic  bacteria.  It  may  be 
vascularized  by  the  extension  into  it  of  capillary  loops  de- 
rived from  adjacent  capillaries.  When  embryonic  tissue  is 
filled  with  blood-vessels,  that  is  to  say,  when  it  is  vascularized, 
it  is  called  granulation-tissue.  Granulation-tissue  is  finally 
converted  into  fibrous  tissue.  The  above  complicated  pro- 
cesses, vascular  and  perivascular,  are  not  accidents  nor  hap- 
hazard freaks,  but  are  Nature's  efforts  to  bring  about  a  cure. 
The  acceleration  of  the  circulation  is  an  attempt  to  wash 
away  offending  material ;  when  this  fails  ensuing  congestion 
is  relieved  by  exudation  and  migration,  the  blood  becoming 
fibrinous  and  more  corpuscular  in  order  that  foreign  bodies 
may  be  encapsuled  or  extruded,  so  that  damaged  parts  may 
be  amply  repaired  and  vital  structures  may  be  protected  and 
shielded.  The  exudation  of  germicidal  blood-serum  may 
destroy  bacteria  in  the  perivascular  tissues. 

Dilatation  is  due  to  the  direct  effect  of  the  irritant  upon 
the  muscle  or  its  nerve-elements.  Retardation  and  stasis  are 
due  to  paralysis  of  the  vessel-wall,  which  paralysis  causes  re- 
sistance to  the  passage  of  the  blood-stream  and  adhesion  of 


54  MODERN  SURGERY. 

the  corpuscles  to  the  vessel,  and  which  deprives  the  blood  of 
a  force  which  normally  urges  it  onward,  namely,  contraction 
of  the  arterioles.  Stasis  can  be  increased  by  the  pressure 
of  an  enormous  exudate,  producing  tension.  Tension  may 
be  so  great  as  to  produce  gangrene. 

Inflammation  in  Non-vascular  Tissue. — A  type  of 
non-vascular  tissue  is  the  cornea,  and  the  cornea  can  inflame. 
When  it  inflames  the  episcleral  vessels  dilate  and  pour  out 
exudate,  and  the  fluid  exudate  and  the  leukocytes  enter  into 
the  corneal  lymph-spaces.  The  exudate  coagulates  and  cell- 
multiplication  ensues  as  in  any  other  inflammation.  If  new 
formation  takes  place,  a  permanent  opacity  mars  the  cornea 
as  a  consequence.  When  cartilage  inflames  it  becomes  filled 
with  leukocytes,  which  are  obtained  from  the  vessels  of  the 
synovial  membrane  or  the  bone,  and  changes  ensue  identical 
with  those  previously  studied. 

Classification  of  Inflammations. — The  various  forms 
of  inflammations  are — (i)  Simple  or  coimno?i,  that  which  is 
due  to  any  ordinary  traumatic,  chemical,  or  thermal  cause, 
and  not  to  bacteria,  such  as  traumatic  periostitis  or  sun  der- 
matitis. It  does  not  tend  particularly  to  spread.  As  a  rule, 
the  cause  of  a  simple  inflammation  is  momentary  in  action ; 
(2)  infective  or  specific,  that  which  is  due  to  micro-organisms, 
as  the  streptococcus  of  eiysipelas.  An  unsuccessful  attempt 
has  been  made  to  charge  all  inflammations  to  bacteria.  It  is 
true  that  bacteria  can  generally  be  found  in  inflammatory 
areas,  but  that  they  are  the  only  causes  of  inflammation  is 
accepted  by  few.  Infective  inflammations  tend  to  spread 
widely;  (3)  traumatic,  which  is  due  to  a  blow  or  an  injury; 
(4)  idiopathic,  which  is  without  an  ascertainable  cause. 
There  is  certainly  a  cause,  even  if  it  cannot  be  pointed  out, 
and  the  term  "  idiopathic  "  means  that  we  do  not  know  the 
cause  ;  (5)  acute,  which  is  rapid  in  course  and  violent  in 
action ;  (6)  chronic,  which  follows  a  prolonged  course ;  (7) 
subacute,  which  is  intermediate  in  violence  and  duration  be- 
tween acute  and  chronic ;  (8)  sthenic,  characterized  by  high 
action.  Occurs  in  strong  young  subjects  ;  (9)  asthenic  or 
adynamic,  occurring  in  the  old,  the  debilitated,  and  the 
broken-down.  It  is  unable  to  reach  a  sufficient  degree  of 
intensity  to  limit  itself;  (10)  parencliyinatous,  affecting  the 
"parenchyma,"  or  active  cells  of  an  organ;  (11)  interstitial, 
affecting  the  connective-tissue  stroma;  (12)  serous,  charac- 
terized by  profuse  non-coagulating  exudation,  as  in  pleuritis, 
or  by  marked  inflammatory  edema ;  ( 1 3)  plastic,  adhesive, 
ox  fibrinous,  characterized  by  an  exudation  which  glues  to- 


INFLAMMA  TION.  5  5 

gether  adjacent  surfaces,  as  in  peritonitis;  (14)  piirulcnt, 
phlcguwnoiis,  or  suppurative,  when  the  pus  cocci  are  present 
and  multiply ;  (15)  /umorrhagic,  when  the  exudate  contains 
many  red  blood-cells,  as  in  strangulated  hernia  and  in  black 
small-pox;  (16)  croupous,  when  an  inflammation  produces 
upon  the  surface  of  a  tissue  a  fibrinous  exudate  which  can- 
not be  organized  (aplastic  lymph),  and  which  is  due  to  the 
action  of  micro-organisms.  It  occurs  most  usually  on  mucous 
membrane;  {ly)  diphtheritic,  \\\\\c\\  differs  from  croupous  in 
the  fact  that  the  false  membrane  is  in  the  tissue  rather  than 
upon  it;  {\^)  gangrenoits,  an  inflammation  resulting  in  death 
of  the  part,  the  gangrene  being  due  to  the  tension  of  the 
exudate  or  the  violence  of  the  poison;  (19)  healthy,  when 
the  tendency  is  to  repair;  (20)  unhealthy,  when  the  ten- 
dency is  to  destruction;  (21)  latent,  an  inflammation  which 
for  some  time  does  not  announce  itself  by  any  obvious 
symptoms,  as  the  inflammation  of  Peyer's  patches  in  typhoid 
fever ;  (22)  contagious,  when  its  own  secretions  can  propa- 
gate it ;  (23)  diy,  without  exudation  ;  (24)  hypostatic,  arising 
in  a  region  of  passive  congestion  (as  a  bed-sore);  (25)  malig- 
nant, due  to  malignant  growths  ;  (26)  catarrhal,  affecting 
mucous  membranes ;  (27)  neuropathic,  due  to  impairment 
of  the  trophic  functions  of  the  nervous  system,  as  in  perfo- 
rating ulcer ;  and  (28)  sympathetic  or  reflex,  due  to  disease 
or  injury  of  a  distant  part,  as  when  orchitis  follows  mumps. 

Extension  of  Inflammation. — Inflammation  extends 
by  continuity  of  structure,  by  contiguity  of  structure,  by 
the  blood,  and  by  the  lymphatics.  Extension  by  continuity 
is  seen  in  phlebitis.  Extension  by  contiguity  is  seen  when  a 
cutaneous  inflammation  advances  and  attacks  deeper  struc- 
tures. Extension  by  the  blood  is  seen  in  the  formation  of 
the  small-pox  exanthem.  Extension  by  the  lymphatics  is 
witnessed  in  a  bubo  following  chancroid. 

Terminations  of  Inflammation. — Inflammation  may 
be  followed  by  a  return  of  the  tissues  to  health,  and  this 
return  may  take  place  by  delitescence,  by  resolution,  or  by 
new  growth.  By  delitescence  is  meant  abrupt  termination 
at  an  early  stage,  as  when  a  quinsy  is  aborted  by  the  ad- 
ministration of  quinin  and  morphin,  and  the  production  of 
a  sweat ;  resolution  means  the  gradual  disappearance  of  the 
symptoms  when  inflammation  has  passed  through  its  regular 
stages ;  and  nezv  grozvtJi  means  that  an  inflammation  has 
lasted  a  considerable  time,  with  ample  blood-supply,  and 
without  suppuration  has  gone  on  to  the  formation  of  em- 
bryonic tissue,  granulation-tissue,  and  fibrous  tissue.     Inflam- 


56  MODERN  SURGERY. 

mation  may  terminate  in  death  of  the  inflamed  part,  or  necro- 
sis. Death  of  the  part  may  be  due  to  suppuration,  ulceration, 
or  gangrene. 

The  causes  of  inflatnination  are — predisposing,  or  those 
residing  in  the  tissues,  and  rendering  them  Hable  to  inflame ; 
and  exciting,  or  those  which  directly  awake  the  process  into 
activity.  The  first  constitute  the  inflammable  material,  the 
second  the  sparks  of  fire. 

Predisposing  causes  are  those  which  impair  the  general 
vigor,  injure  the  blood,  weaken  the  tissues,  or  lower  nutri- 
tive activities.  Among  these  causes  are  shock,  hemorrhage, 
nervous  irritation,  gout,  rheumatism,  diabetes,  Bright's  dis- 
ease, and  syphilis.  Plethora  renders  a  person  liable  to 
sthenic  inflammations  (those  characterized  by  high  action). 
Tissue-debility  renders  one  prone  to  adynamic  or  asthenic 
inflammations. 

Exciting  Causes. — The  exciting  causes  of  inflammation  are 
— traumatic,  as  blows  and  mechanical  irritation  ;  chemical,  as 
the  stings  of  insects,  ivy  poison,  etc. ;  thermal,  heat  and  cold ; 
and  specific,  the  micro-organisms,  causing,  for  instance,  tuber- 
cular peritonitis  or  erysipelas. 

Symptoms. — Inflammation  announces  its  presence  by 
symptoms  which  are  both  local  and  constitutional.  The  local 
symptoms  are  heat,  pain,  discoloration,  swelling,  and  dis- 
ordered function ;  the  chief  constitutional  symptom  is  fever. 

Local  Symptoms  of  Inflammation. — The  most  promi- 
nent local  symptoms  were  known  centuries  ago  to  the 
famous  Roman  Celsus,  who  stated  them  as  "  rubor,  calor  cum 
tumore  et  dolore  " — redness  and  heat  with  swelling  and  pain. 
As  set  forth  to-day,  the  local  symptoms  are — (i)  heat;  (2) 
pain;  (3)  discoloration;  (4)  swelling;  and  (5)  disordered 
function. 

Heat  is  due  to  the  passage  of  an  increased  quantity  of 
blood  through  the  damaged  area  and  to  the  arrival  at  the 
surface  of  the  body  of  warm  blood  from  internal  parts.  Al- 
though an  inflamed  part  may  be,  and  usually  is,  warmer 
than  the  surrounding  parts,  its  temperature  is  never  greater 
than  the  temperature  of  the  blood.  This  increase  of  heat  is 
especially  noticeable  when  we  contrast  the  feeling  of  an  arm 
affected  with  erysipelas  with  a  sound  arm ;  the  diseased  arm 
feels  much  warmer,  but  still  its  temperature  is  not  above  the 
general  body-temperature.  The  extremities  in  health,  as  is 
well  known,  show  on  the  surface  a  temperature  below  that 
of  the  blood ;  in  an  inflamed  state  their  temperature  may 
nearly  equal  that  of  the  blood.     Heat  is  always  present  in 


INFLAMMA  TIOX.  5  J 

inflammation.  The  surgeon  examines  for  heat  by  placing 
his  hand  upon  the  suspected  area  and  then  placing  it  upon 
a  corresponding  portion  of  the  opposite  side  of  the  patient. 
If  great  accuracy  is  desired,  a  surface  thermometer  is  used. 

Pain  is  a  constant  and  a  conspicuous  symptom.  It  is  due 
to  stretching  of  or  pressure  upon  nerves  from  exudate ;  to 
irritation  of  nerves ;  or  to  inflammation  in  the  nerves  them- 
selves, producing  cellular  changes.  Pain  is  associated  with 
tenderness  (pain  on  pressure),  it  is  aggravated  by  motion 
and  by  a  dependent  position  of  the  part,  and  it  varies  in 
degree  and  in  character.  In  serous  membranes  it  is  acute 
and  lancinating,  like  dagger-thrusts  ;  in  connective  tissue  it 
is  acute  and  throbbing ;  in  large  organs  it  is  dull  and  heavy ; 
in  the  bone  it  is  gnawing  or  boring ;  in  the  skin  and  mucous 
membrane  it  is  itching,  burning,  smarting,  or  stinging ;  in 
the  urethra  it  is  scalding ;  in  the  testicle  it  is  sickening  or 
nauseating ;  in  the  teeth  it  is  throbbing ;  and  in  inflamma- 
tion under  tense  fascia  it  is  pulsatile.  Pain  in  inflammation 
after  presenting  itself  in  one  form  may  change  in  character. 
If  a  pain  becomes  markedly  throbbing,  suppuration  may 
be  anticipated.  Pain  does  not  always  occur  at  the  seat  of 
trouble,  but  may  be  felt  at  some  distant  point.  This  is  known 
as  a  "  sympathetic  "  pain,  and  means  that  a  nervous  communi- 
cation exists  between  the  inflamed  part  and  a  distant  area,  a 
nerve-trunk  referring  pain  to  its  peripheral  distribution. 

Pain  of  hepatitis  is  often  felt  in  the  right  shoulder.  Pain 
at  the  point  of  the  shoulder  is  felt  also  in  gall-stones  and 
in  cancer  of  the  liver.  The  pain  arises  in  filaments  of  the 
pneumogastric  from  the  hepatic  plexus,  which  filaments 
reach  the  spinal  accessor^',  pain  being  expressed  in  the 
branches  of  the  spinal  accessor}^  which  supply  the  trapezius 
and  communicate  with  the  third  and  fourth  cervical  nerves.^ 

Pai)i  of  coxalgia  is  often  felt  on  the  inside  of  the  knee, 
because  the  obturator  nerve,  which  sends  a  branch  to  the 
ligamentum  teres,  also  sends  a  branch  to  the  interior  and 
to  the  inner  side  of  the  knee-joint. 

Inflammation  of  an  eye  with  increased  tension  causes 
brow-ache.  Inflammation  of  the  neck  of  the  bladder  causes 
pain  in  the  head  of  the  penis.  Inflammation  of  a  testicle 
causes  pain  in  the  groin.  Renal  calculus  and  pyelitis  cause 
pain  in  and  retraction  of  the  testicle,  and  pain  in  the  thigh. 

If  the  covering  of  an  organ  is  involved,  pain  becomes 
more  violent ;  for  instance,  a  hepatitis  becomes  much  more 

•  Embleton's  view  in  Hilton  on  Rest  and  Pain,  a  book  every  student  should 
read. 


58  MODERN  SURGERY. 

painful  when  the  perihepatic  structures  are  attacked.-  In- 
flammation without  pain  is  known  as  "  latent  "  (as  the  inflam- 
mation of  Peyer's  patches  in  typhoid).  The  sudden  disap- 
pearance of  inflammatory  pain,  when  not  due  to  opiates, 
suggests  the  possibility  of  gangrene,  for  analgesia  exists  in 
gangrene.  The  characteristics  of  inflammatory  pain  are  that 
it  cornes  on  gradually,  has  a  fixed  seat,  is  continuous,  is 
attended  by  other  inflammatory  symptoms,  and  is  increased 
by  motion,  by  pressure,  and  by  the  hanging  down  of  the 
part.  If  there  be  no  tenderness  in  a  part,  the  source  of  the 
pain  is  not  local  infl.ammation ;  but  tenderness  may  exist 
when  there  is  no  local  inflammation,  as  in  pain  referred  from 
a  distant  part.  Pain  of  inflammation  does  not  correspond 
to  an  exact  nervous  distribution.  If  pain  corresponds  ex- 
actly to  an  area  of  a  nerve's  distribution,  the  cause  of  it  is 
acting  on  the  nerve-trunk  or  on  its  roots.  If  the  cutaneous 
surface  is  involved,  the  lightest  touch  causes  pain.  If  touch- 
ing the  skin  produces  no  pain,  but  deep  pressure  does  pro- 
duce it,  the  deeper  structures  are  the  source.  Pain  in  mus- 
cle and  ligament  is  developed  by  motion  :  in  muscle,  by 
contraction,  but  not  by  passive  movements  with  the  muscle 
relaxed ;  in  ligament  pain  is  developed  by  active  or  passive 
movements  which  stretch  the  ligament.  If,  for  example,  a 
man  with  a  stiff  neck  has  pain  on  the  right  side  of  the  back 
of  his  neck  on  voluntarily  turning  his  face  toward  the  left 
shoulder,  but  is  without  pain  when  his  face  is  turned  by  the 
surgeon,  who,  conversely,  induces  pain  by  turning  the 
patient's  face  far  to  the  right,  this  condition  indicates  the 
trouble  to  be  muscular.  If,  however,  no  pain  arises  on 
turning  the  face  to  the  right,  but  it  is  manifest  on  turning 
the  face  actively  or  passively  to  the  left,  the  pain  is  in  those 
ligaments  which  stretch  when  the  face  is  turned  to  the  left 
(A.  Pearce  Gould).  In  inflammation  of  the  synovial  mem- 
brane gentle  passive  motion  in  any  direction  causes  pain. 

The  pain  of  colic  differs  from  that  of  inflammation.  It  is 
sudden  in  onset,  intermits,  recurs  in  paroxysms,  and  is  re- 
lieved by  pressure.  The  pain  of  inflammation  is  gradual  in 
onset,  is  continuous,  and  is  made  worse  by  pressure.  The 
pain  of  neuralgia  is  often  preceded  by  the  onset  of  cutaneous 
anaesthesia  of  the  skin  of  the  part,  is  very  paroxysmal,  comes 
suddenly,  darts  through  recognized  nerve-areas,  lasts  some 
hours,  and  is  apt  to  recur  at  a  certain  hour.  It  presents  no 
general  tenderness,  as  does  inflammation,  but  w^e  may  find 
several  points  which  are  acutely  sensitive  to  pressure  (Val- 
leix's  points  dotdoiiraix).     The  tender  spots  of  Valleix  are 


INFLAMMATION.  59 

met  with  in  inveterate  neuralgia,  and  occur  at  points  where 
nerves  "  pass  from  a  deeper  to  a  more  superficial  level,  and 
particularly  where  they  emerge  from  bony  canals  or  pierce 
fibrous  fascia  "  (Anstie). 

Pain  is  often  of  great  value  by  calling  attention  to  parts 
diseased ;  but  it  may  be  a  great  evil,  racking  the  organism 
and  even  causing  death.  If  pain  continues  long,  it  becomes 
in  itself  formidable  :  it  prevents  sleep,  it  destroys  appetite, 
and  it  disorders  the  mind,  and  one  of  the  surgeon's  highest 
duties  is  to  relieve  it.  The  physiognomy  or  expression  of 
physical  pain  presents  the  following  characteristics  :  Heavy, 
fulness  about  the  eyes,  and  dropping  of  the  angles  of  the 
mouth,  added  to  appearances  due  to  anemia,  widespread 
tremor,  etc.  The  absence  of  the  physiognomy  of  pain  in  a 
person  who  complains  of  great  agony  is  a  strong  indication 
that  the  patient  exaggerates  the  gravity  of  his  sufferings  or 
deliberately  deceives. 

Discoloration  arises  from  determination  of  blood  to  the 
part ;  hence  the  more  vascular  the  tissue  the  greater  the 
discoloration.  A  non-vascular  tissue  presents  no  discolora- 
tion, though  we  find  discoloration  adjacent  in  the  zone  of 
blood-vessels  which  furnish  the  tissue  with  nutriment.  Dis- 
coloration is  most  intense  at  the  focus  or  centre  of  inflam- 
matory action.  Discoloration  varies  in  tint  and  in  character 
according  to  the  tissue  implicated  and  the  nature  of  the  in- 
flammation. It  may  be  circumscribed  or  diffuse.  Arbores- 
cent redness  means  a  distribution  in  dendritic  lines.  Linear 
discoloration  signifies  redness  running  in  straight  lines,  as  in 
phlebitis.  Punctiform  discoloration  occurs  in  points,  and  is 
due  to  vascular  rupture.  Maculiform  redness  resembles  an 
ecchymosis  or  blotch.  Dusky  discoloration  points  to  sup- 
puration. 

Inflammation  of  the  throat  and  skin  produces  scarlet  dis- 
coloration ;  inflammation  of  the  sclerotic  coat  of  the  eye  and 
of  the  fibrous  coat  of  muscle  produces  lilac  or  bluish  discol- 
oration ;  inflammation  of  the  iris  produces  brick-dust,  gray- 
ish, or  brown  discoloration  ;  erysipelas  causes  a  yellowish- 
red  discoloration  ;  secondary  syphilis  causes  a  copper-hued 
discoloration  ;  and  tonsillitis  causes  a  livid  discoloration.  A 
scrofulous  ulcer  is  of  a  purple  color  on  the  edge.  Gangrene 
is  shown  by  a  black  discoloration.  A  scorbutic  ulcer  is  sur- 
rounded by  an  area  of  violet  color. 

Redness  as  a  sign  of  inflammation  must  be  permanent 
and  joined  with  other  symptoms.  Redness  due  to  inflam- 
mation  disappears  on  pressure,  but  returns  as  soon  as  the 


60  MODERN  SURGERY. 

pressure  is  removed.  If  redness  is  due  to  staining  of  the 
surface  by  dye,  pigmentation,  or  extravasation  of  blood,  press- 
ure will  not  blanch  the  spot.  If  on  taking  off  pressure  the 
redness  of  inflammation  rapidly  returns,  the  circulation  is  ac- 
tive ;  if,  on  the  contrary,  it  very  slowly  reappears,  the  circula- 
tion is  very  sluggish  and  gangrene  is  threatened.  Subcuta- 
neous hemorrhage  gives  rise  to  a  purple-red  color  which 
does  not  fade  when  subjected  to  pressure.  Stains  of  the 
surface  by  dyes  fail  to  disappear  on  pressure,  are  distributed 
over  a  considerable  surface,  show  a  hue  which  is  uniform 
throughout,  are  obviously  superficial,  are  not  associated  with 
other  signs  of  inflammation,  and  can  be  washed  away. 

A.  Pearce  Gould,  in  his  excellent  little  work  upon  Sur- 
gical Diagnosis,  tells  us  that  the  color  of  a  hyperemic  sur- 
face may  furnish  important  information.  Lividity  may  mean 
failure  of  the  heart  and  lungs,  or  simply  venous  congestion 
in  the  part.  In  lividity  from  obstruction  of  the  lungs  or 
heart  the  color  slowly  returns  after  pressure  has  driven  it 
out.  In  lividity  due  to  local  congestion  the  color  quickly 
returns  when  pressure  is  released  and  the  dilated  veins  are 
often  distinctly  visible. 

Szvelling  or  tumefaction  arises  in  small  part  from  vascular 
distention,  but  chiefly  from  effusion  and  cell-multiplication. 
The  more  loose  cellular  material  a  part  contains,  the  more  it 
swells  ;  hence  the  eyelids,  scrotum,  vulva,  tonsils,  glottis,  and 
conjunctivae  swell  very  largely  when  inflamed.  A  swelling 
is  soft  or  edematous  when  due  to  uncoagulable  effusion,  and 
it  is  hard  and  elastic  when  produced  by  coagulated  exudate 
or  embryonic  tissue.  Swelling  may  do  good  by  unloading 
the  vessels  and  acting  like  a  blister  or  local  bleeding,  or  it 
may  do  great  harm  by  pressing  upon  the  vessels  and  cut- 
ting off  the  blood-supply.  Swelling  of  the  conjunctiva,  or 
chemosis,  may  cause  sloughing  of  the  cornea,  and  swelling 
of  the  prepuce  may  cause  gangrene.  A  swelling  may  do 
harm  by  obstruction  of  a  natural  passage,  as  in  edema  of  the 
glottis,  or  by  compression  of  a  normal  channel,  as  in  the 
swelling  of  the  perineum.  A  swollen  area  may  be  covered 
with  blisters  or  blebs.  This  condition  is  noted  particularly 
in  burns. 

Disordered  function  is  always  present  in  inflammation. 
It  may  be  manifested  by  increased  tenderness  or  sensibility, 
a  slight  touch,  it  may  be,  producing  torturing  pain.  Parts 
almost  or  entirely  destitute  of  feeling  when  healthy  (as  ten- 
dons, ligaments,  and  bones)  become  highly  sensitive  when 
inflamed.     It  may  be  manifested  by  increased  irritability.     In 


INFLAMMATION.  6 1 

dysentery  the  colon  constantly  contracts  and  expels  its  con- 
tents ;  the  stomach  does  likewise  in  gastritis  ;  and  the  blad- 
der acts  similarly  in  cystitis.  Spasmodic  twitching  of  the 
eyelids  occurs  in  conjunctivitis,  and  twitching  of  the  muscles 
in  fracture  and  after  amputation. 

hnpainiiciit  of  Special  Function. — In  inflammation  of  the 
eye,  when  an  attempt  is  made  to  look  at  objects,  the  lids 
close  spasmodically,  and  even  a  little  light  causes  great  pain 
and  lachrymation  (photophobia).  In  inflammation  of  the 
ear  noises  cause  great  suffering,  and  even  when  in  a  quiet 
room  the  patient  has  subjective  buzzing  and  roaring  sounds 
in  his  ears  (tinnitus  aurium).  In  coryza  the  sense  of  smell, 
in  glossitis  the  sense  of  taste,  in  dermatitis  the  sense  of  touch, 
and  in  laryngitis  the  voice  may  be  lost.  In  inflammation  of 
the  brain  the  mind  is  affected ;  in  arthritis  the  joints  can 
scarcely  if  at  all  be  used  ;  and  in  myositis  it  is  difficult  and 
painful  to  employ  the  muscles. 

Derangement  of  Secretions. — In  dermatitis  the  sweat  is  not 
thrown  off;  in  hepatitis  bile  is  not  properly  secreted;  and  in 
nephritis  urea  is  not  satisfactorily  removed.  The  secretions 
may  undergo  important  changes  of  composition.  Pneu- 
monia causes  rusty  sputum,  and  dysentery'  causes  bloody 
mucus  (Gross). 

Derangement  of  Absorbejits. — In  the  height  of  an  inflam- 
mation the  absorbents  are  blocked  and  clogged  by  coagu- 
lated fibrin,  and  they  cannot  perform  their  offices. 

Constitutional  symptoms  of  acute  inflammation  may  be 
absent,  and  often  are  in  moderate  or  limited  inflammations ; 
but  in  severe,  extensive,  or  infective  inflammations  the  symp- 
tom-group known  ^js,  fever  is  certain  to  exist.  This  is  known 
as  symptomatic,  sympathetic,  or  inflammatory  fever,  and  it 
arises  in  non-septic  cases  from  the  absorption  of  aseptic  pyrog- 
enous  exudate  and  in  microbic  inflammations  from  absorption 
of  pyrogenous  toxic  products.  In  young  and  robust  individ- 
uals an  acute  non-microbic  inflammation  causes  a  fever  char- 
acterized by  full,  strong  pulse,  flushed  face,  coated  tongue, 
dry  skin,  nausea,  constipation,  and  possibly  acute  delirium 
(the  sthenic  type  of  the  older  authors).  In  broken-down  and 
exhausted  individuals  an  ordinar)^  inflammation,  and  in  any 
individuals  a  bacterial  inflammation  may  cause  a  fever  with 
t\'phoid  symptoms  (the  typhoid,  asthenic,  or  adynamic  type). 
In  inflammatory  conditions  the  leukocytes  are  markedly  in- 
creased in  number,  the  condition  being  spoken  of  as  leuko- 
cytosis or  transient  leukocythemia.  Blood  plaques  are  also 
increased.    The  fibrin-ferment  is  obtained  from  the  white  cor- 


62  MODERN  SURGERY. 

puscles  ;  it  is  liberated  as  the  corpuscles  break  up  in  the  ex- 
udate, and  acting  on  the  liquor  sanguinis  forms  fibrin.  The 
absorption  of  fibrin-ferment  many  believe  causes  aseptic  fever 
(page  88).  Inflammatory  blood  contains  an  increased  amount 
of  albumin  and  salts.  If  a  person  with  inflammatory  fever  is 
bled,  the  blood  coagulates  rapidly,  the  clot  sinks,  and  there 
is  found  on  the  surface  a  cup-shaped  coat,  made  up  of  liquor 
sanguinis  and  white  cells,  known  as  the  "  buffy  coat,"  but 
this  is  not  a  sign  of  inflammation  and  occurs  normally  in  the 
blood  of  the  horse.  The  buffy  coat  forms  when  blood  con- 
tains a  great  number  of  leukocytes,  because  these  leukocytes 
sink  more  slowly  than  do  the  red  corpuscles.  Cupping  oc- 
curs because  the  white  corpuscles  sink  more  slowly  by  the 
sides  of  the  tube  than  far  from  the  sides. 

Treatment  of  Inflammation. — The  first  rule  in  treat- 
ing an  inflammation  must  be  to  remove  the  exciting  cause.  If 
this  cause  is  a  splinter  in  the  part,  take  out  the  splinter  ;  if 
it  is  a  foreign  body  in  the  eye,  remove  the  foreign  body ;  if 
urine  is  extravasated,  open  and  drain ;  take  off  pressure 
from  a  corn ;  pull  out  an  ingrown  nail,  and  remove  irritants 
from  an  infected  area  by  asepticizing.  The  rule,  remove  the 
cause,  applies  to  a  chronic  as  well  as  to  an  acute  inflamma- 
tion. If  the  cause  of  an  inflammation  was  momentary  in 
action  (as  a  blow),  we  cannot  remove  it,  for  it  has  already 
ceased  to  exist.  After  removing  the  cause,  endeavor  to 
bring  about  a  cure  by  local  and  constitutional  treatment. 

Local  Treatment  of  Inflammation. — It  must  be  remem- 
bered that  the  division  of  inflammation  into  stages  is  natural, 
and  not  artificial,  and  that  a  remedy  which  does  good  in  one 
stage  may  do  harm  in  another.  Certain  agents  are  suited  to 
all  stages  of  an  inflammation,  namely,  rest  and  elevation. 

Rest  is  of  infinite  importance,  and  is  always  indicated  in 
acute  inflammation.  Its  principles  were  first  thoroughly 
studied  by  Hilton.^  The  means  of  securing  rest  differ  with 
the  structure  or  the  part  diseased.  When  rest  is  used,  do 
not  employ  it  too  long.  In  cerebral  concussion  rest  must  be 
secured  by  quiet,  by  darkness,  by  the  avoidance  of  stimu- 
lants and  meat,  by  the  application  of  ice  to  the  head,  and 
by  the  use  of  purgatives  to  prevent  reflex  disturbance  and 
the  circulation  of  poisons  in  the  blood.  In  inflamed  joints 
rest  must  be  obtained  by  proper  position,  associated  in  many 
cases  with  the  adjustment  of  splints  or  plaster,  or  the  em- 
ployment of  extension. 

In  pleurisy  partial   rest  can  be  secured  by  strapping  the 

^  Lectures  upon  Rest  and  Pain. 


IXFLAMMA  TIOX.  63 

affected  side  with  adhesive  plaster  or  by  using  a  bandage  or 
a  binder  to  Hmit  respiratory  movements.  \Vi  fractures  Nature 
procures  rest  by  her  spHnts — the  callus — and  the  surgeon  pro- 
cures rest  by  his  splints — immovable  dressings,  or  extension. 
In  fractures  of  the  ribs  strap  the  chest  on  the  injured  side.  In 
cancer  of  the  rectum  a  colostomy  secures  rest  for  the  damaged 
bowel.  In  enteritis  opium  gives  rest  to  the  bowel  by  stop- 
ping peristalsis.  In  cystitis  rest  is  obtained  by  opium  and 
belladonna,  which  paralyze  the  muscular  fibres  of  the  blad- 
der. The  use  of  the  catheter  gives  rest  to  the  bladder  by 
removing  urine.  A  cystotomy  allows  complete  rest  by  per- 
mitting the  bladder  to  suspend  its  function  as  a  reservoir  of 
urine.  In  vesical  calculus  rest  is  obtained  by  cutting  or  crush- 
ing the  stone.  In  inflamed  mucous  membranes  rest  is  secured 
(from  the  contact  of  irritants)  by  touching  them  with  silver 
nitrate,  which  forms  a  protective  coat  of  coagulated  albumin. 
Opening  an  abscess  gives  its  walls  rest  from  tension.  In  i>i- 
flammations  of  the  eye  light  must  be  excluded  to  obtain  com- 
plete rest,  but  tolerable  satisfactory  rest  is  given  in  some  cases 
by  the  use  of  glasses  of  a  peacock-blue  tint.  In  aneurism  the 
operation  of  ligation  cuts  off  the  blood-current  and  giv^es  rest 
to  the  sac.  In  hernia  the  operation  gives  rest  from  pres- 
sure. Instances  of  the  value  of  rest  could  indefinitely  be 
multiplied. 

Elevation  partly  restores  circulatory  equilibrium.  A  felon 
is  less  painful  when  the  hand  is  held  up  in  a  sling  than  when 
it  is  dependent.  A  congestive  headache  is  worse  during  re- 
cumbency. A  gouty  inflammation  in  the  great  toe  is  more 
painful  with  the  foot  lowered  than  when  it  is  raised.  A  tooth- 
ac/ie  becomes  worse  on  lying  down. 

Relaxation  is  in  reality  a  form  of  rest,  and  consists  in 
placing  the  part  in  an  easy  position.  In  synovitis  of  the 
knee  semiflexion  of  the  knee-joint  lessens  the  pain.  In 
muscular  inflammations  relaxation  relie\-es  the  pain. 

Certain  agents  are  suited  to  the  stage  of  vascular  engorge- 
ment, increased  arterial  tension,  and  beginning  effusion. 
These  agents  are — (i)  local  bleeding  or  depletion  ;  (2)  cut- 
ting off  the  blood-supply  ;  and  (3)  cold. 

Local  bleeding  or  depletion  is  the  abstraction  of  blood  from 
the  inflamed  area.  This  abstraction  relieves  circulator}'  re- 
tardation and  causes  the  blood  to  move  rapidly  onward ; 
the  corpuscles  clinging  to  the  vessel-walls  are  washed  away, 
the  capillaries  shrink  to  their  natural  size,  and  the  exudate 
is  absorbed.  In  other  words,  local  blood-letting  increases 
the  rate  of  the  circulation,  though  not  its  force. 


64  MODERN  SURGERY. 

The  methods  of  bleeding  locally  are — («)  puncture ;  {B) 
scarification  ;  {c)  leeching ;  and.  {d^  cupping. 

Puncture  is  recommended  in  inflammation,  not  only 
because  it  abstracts  blood  locally,  but  also  because  it  gives 
an  exit  to  effusion  under  fibrous  membranes.  It  is  very  use- 
ful in  relieving  tension — for  instance,  in  epididymitis.  It  is 
performed  with  a  tenotome  and  with  aseptic  precautions.  If 
numerous  punctures  are  made,  the  procedure  is  termed 
"  multiple  puncture."  This  is  very  useful  when  applied  to 
the  inflamed  area  around  a  leg-ulcer.  The  late  Prof  Joseph 
Pancoast  was  very  fond  of  employing  multiple  punctures, 
designating  the  operation  "  the  antiphlogistic  touch  of  the 
therapeutic  knife." 

Scarification  or  Incision. — By  means  of  scarification  we 
bleed  locally,  evacuate  exudates,  and  relieve  tension.  One 
cut  or  many  cuts  may  be  made,  and  these  cuts  may  be  deep 
or  may  not  even  go  entirely  through  the  skin,  according  to 
circumstances.  Multiple  incision  is  very  useful  appHed  to 
inflamed  ulcers,  ulcers  in  danger  of  gangrene,  and  to  almost 
any  condition  of  great  tension. 

Leeching. — Leeches  must  not  be  applied  to  a  region  plen- 
tifully endowed  with  loose  cellular  tissue,  as  great  swelling 
and  discoloration  are  sure  to  ensue.  These  regions  are  the 
prepuce,  labia  majora,  scrotum,  and  eyelids.  Leeches  should 
never  be  applied  to  the  face  (because  of  the  scar),  near 
specific  scars  or  inflammations,  nor  over  a  superficial  artery, 
vein,  or  nerve.  A  leech  is  best  applied  at  the  periphery 
of  an  inflammation  and  between  an  inflammation  and  the 
heart.  To  leech  at  the  inflammatory  focus  only  aggravates 
the  case.  Before  applying  leeches,  wash  the  part  and  shave 
it  if  hairy.  If  the  leeches  will  not  bite,  smear  the  part  with 
milk  or  with  a  little  blood.  In  u.sing  a  leech,  place  it  on 
the  skin  under  a  glass  tube  or  an  inverted  wine-glass.  Never 
pull  off  a  leech  :  let  it  drop  off;  and  if  it  refuses  to  do  so, 
sprinkle  it  with  salt.  After  removing  a  leech,  employ  warm 
fomentations  if  continued  bleeding  is  desired.  Sometimes 
the  bleeding  persists,  but  this  may  be  arrested  by  styptic 
cotton  and  pressure.  Leeching  leaves  permanent  triangular 
scars.  The  Swedish  leech,  which  is  preferred  to  the  Ameri- 
can, draws  from  four  to  six  drachms.  Leeching  has  both  a 
constitutional  and  a  local  effect.  It  is  at  the  present  time 
used  comparatively  rarely,  but  it  is  employed  by  some  sur- 
geons over  the  spermatic  cord  in  epididymitis,  on  the  temple 
in  ocular  inflammation,  and  over  the  right  iliac  region  in  mild 
cases  of  appendicitis. 


IXFLAMMA  riON.  65 

Cupping:  Wet  dtps. — In  wet  cupping  apply  a  cup  for  a 
moment,  remove  it,  incise  or  puncture  the  skin,  and  apply 
the  cup  again  to  draw  the  requisite  amount  of  blood.  Baron 
Heurteloup  devised  an  instrument  (Fig.  22)  in  which  the 
incision  is  made  by  a  scarifier.  The  blood  is  drawn  by  a 
pump,  the  tube  being  placed  upon  the  cut  area  and  the 
withdrawal  of  the  piston  creating  a  vacuum.  This  instru- 
ment is  known  as  the  "  artificial  leech."  Wet  cupping  is  of 
value  in  pleuritis,  pericarditis,  and  nephritis. 

Cutting  off'  the  Blood-supply. — Onderdonk,  of  New  York, 
in  181 3  recommended  ligation  of  the  main  artery  of  a  limb 
for  the  cure  of  inflammation  in  important  structures  supplied 
by  the  vessel.  The  procedure  was  warmly  advocated  by 
Campbell,  of  Georgia,  for  the  treatment  of  gunshot-wounds 


Fig.  22. — Heurteloup's  artificial  leech. 

of  joints.  This  plan  of  treatment  is  now  not  to  be  considered 
for  a  moment ;  antisepsis  furnishes  us  with  a  safer  and  more 
certain  plan.  Vanzetti,  of  Padua,  advocates  digital  pressure 
to  cut  off  the  blood-supply  to  an  inflamed  part. 

Cold  is  a  very  powerful  and  an  extremely  useful  agent. 
It  constringes  the  vessels,  prevents  migration  of  corpuscles, 
favors  the  absorption  of  exudate,  retards  cell-proliferation, 
and  relieves  pain,  swelling,  and  tension.  Cold  must  not  be 
applied  to  the  old  or  to  the  feeble,  as  it  may  induce  gan- 
grene. It  is  harmful  in  advanced  inflammations  or  severe 
congestions  (as  strangulated  hernia).  There  are  two  forms 
of  cold,  the  dry  and  the  wet. 

Wet  Cold. — To  apply  wet  cold,  the  part  is  wrapped  in 
wet  linen  or  muslin  and  laid  upon  a  rubber  sheet  folded  like 
a  trough  and  emptying  into  a  bucket.  A  vessel  filled  with 
cold  water  is  placed  upon  a  higher  level  than  the  bed.  A 
wet  lamp-wick  is  now  taken,  one  end  is  inserted  into  the 
water  of  the  vessel,  and  the  other  end  is  laid  upon  the  part. 


66  MODERN  SURGERY. 

Capillary  action  and  gravity  combine  to  keep  the  part  moist. 
A  rubber  tube  may  be  used  instead  of  a  wick.  If  a  tube  is 
employed,' tie  it  in  a  knot  or  clamp  it  so  that  the  fluid  is  de- 
livered drop  by  drop  (Fig.  23).  Ordinary  water  or  iced 
water  can  be  used.  If  the  water  be  too  warm,  it  can  be 
reduced  to  about  45°  F.  by  adding  i  part  of  alcohol  to  every 
4  parts  of  water.  A  mixture  of  5  parts  of  nitrate  of  potas- 
sium, 5  parts  of  chlorid  of  ammonium,  and  16  parts  of  water 
produces  great  cold.     If  wet  cold  is   used  upon  an  open 


Fig.  23. — Siphon  (Esmarch). 

wound,  the  fluid  should  be  antiseptic.  Irrigation  by  cold 
fluid  is  rarely  employed  at  the  present  day.  In  severe  con- 
junctivitis wet  cold  is  applied  by  means  of  cloths  soaked  in 
ice-water  and  frequently  changed.  Evaporating  lotions  owe 
a  portion  of  their  efficacy  to  the  cold  they  induce. 

Diy  cold  is  applied  by  means  of  a  rubber  bag  or  a  blad- 
der filled  with  ground  or  finely  cracked  ice,  several  folds  of 
flannel  being  first  laid  over  the  part.  A  part  can  be  encircled 
with  a  rubber  tube  through  which  ice-water  is  made  to  flow 


INFI.AMMA  TJON. 


67 


(Fig.  24).  Leiter's  tubes,  which  are  made  to  fit  various  re- 
gions and  which  carry  a  stream  of  cold  water,  can  also  be 
used.  An  ice-bag,  if  applied  at  once,  is  the  best  treatment 
for  a  sprained  joint.  Ice-bags  are  very  useful  in  acute  mye- 
litis, meningitis,  joint-inflammation,  epididymitis,  and  other 
acute  inflammations  in  the  early  stage. 

Certain  agents  are  suited  to  the  stage  of  fully  developed 
inflammation,  when  we  have  a  great  deal  of  swelling  due  to 
effusion  and  cell-proliferation.  The  indication  in  this  stage 
is  to  abate  swelling  by  promoting  absorption.  This  is  accom- 
plished by  (i)  compression;  (2)  the  local  use  of  astringents 


Fig.  24. — The  Esmarch  cooling  coil. 

and  sorbefacients  ;  (3)  the  douche ;  (4)  massage  ;  and  (5)  in- 
termittent heat. 

Compression  is  the  agent  which  is  especially  useful  in  fully 
developed  or  in  chronic  inflammation,  but  it  will  do  good 
also  in  the  first  stage.  Compression  is  of  great  usefulness  : 
it  supports  the  vessels  and  causes  them  to  drink  up  effusion, 
and  it  strongly  rouses  the  absorbents.  This  agent  is  valu- 
able in  most  external  inflammations  with  much  swelling.  In 
erysipelas  of  an  extremity  the  part  should  be  elevated  and 
the  extremity  bandaged  from  the  periphery  to  the  body.  In 
ulcers,  especially  those  with  hard  and  blue  edges,  the  use 
of  Martin's  elastic  bandage  or  of  straps  of  adhesive  plaster 
gives  decided  relief  In  chronic  inflammation  of  a  joint  elas- 
tic compression  is  of  great  value.     In  epididymitis,  after  the 


68  MODERN  SURGERY. 

acute  stage,  the  testicle  may  be  strapped  with  adhesive  plas- 
ter. In  lymphadenitis  compression  by  a  weight  or  by  a 
bandage  is  vQxy  generally  employed.  In  fractures  compres- 
sion not  only  antagonizes  spasm,  but  often  combats  the 
swelling  and  pain  of  inflammation.  Compression  must  be 
judicious  :  it  must  never  be  too  forcible,  and  it  must  not  be 
applied  to  a  limb  without  including  the  extremity  of  it 
(never,  for  instance,  strongly  compress  the  elbow  without 
including  the  hand,  nor  the  palm  without  bandaging  the 
fingers).  Injudicious  compression  causes  severe  pain,  and 
may  produce  gangrene. 

Astringents  and  Sorbcfacients :  Solutions  of  Acetate  of  Lead. 
— Ammonium  chlorid  was  formerly  employed  in  the  strength 
of  oj  to  2  quarts  of  water;  but  if  long  used,  it  produces  pus- 
tules and  thus  causes  irritation  and  pain.  A  solution  of  the 
acetate  of  lead  is  astringent  and  sorbefacient ;  it  promotes  the 
contraction  of  distended  vessels,  accelerates  the  blood-cur- 
rent, and  urges  the  absorbents  to  increased  activity.  This 
agent,  in  practice,  is  usually  mixed  with  laudanum,  as  fol- 
lows :  Tinctura  opii,  f.lj ;  Hquor  plumbi  subacetatis,  f 5j  ; 
aqua,  Oj.  This  solution,  spoken  of  as  lead-water  and  laud- 
anum, is  extensively  used  and  is  very  soothing.  It  can  be 
employed  cold,  the  evaporation  which  it  undergoes  cooling 
the  part.  It  is  best  applied  by  soaking  a  double  layer  of 
flannel  in  the  lead-water,  laying  it  on  the  affected  part,  and 
by  means  of  a  sponge  squeezing  more  of  the  lotion  upon  it 
from  time  to  time.  If  it  is  desired  to  have  it  very  cold,  an 
ice-bag  can  be  placed  upon  the  soaked  flannel.  Lead-water 
and  laudanum  may  be  used  warm,  the  flannel  being  covered 
with  oiled  silk  or  waxed  paper  or  a  piece  of  rubber.  If  it  is 
desired  hot  (veritably  a  poultice),  the  lead-water  is  heated 
before  the  flannel  is  soaked  in  it.  The  soaked  flannel  is  ap- 
plied to  the  part  and  covered  with  a  rubber-dam,  and  a  hot- 
water  bag  is  placed  upon  the  dressing.  Lead-water  is  not 
used  in  treating  open  wounds. 

Tincture  of  iodin  acts  like  lead  acetate.  It  is  astringent, 
sorbefacient,  counterirritant,  and  antiseptic.  It  must  not  be 
used  pure.  For  adults  it  should  be  diluted  with  an  equal 
amount  of  alcohol,  and  for  children  with  3  parts  of  alcohol. 
In  using  iodin,  paint  it  upon  the  part  with  a  camel's-hair 
brush  and  fan  it  dry,  applying  one  or  more  coats.  The  re- 
peated application  of  iodin  to  the  skin  is  of  great  benefit  in 
inflammation  of  the  glands,  muscles,  tendons,  joints,  and  peri- 
osteum. Iodin  is  apt,  after  a  time,  to  vesicate,  and  must 
not  be  used  in  full  strength,  because  it  is  irritant.     It  is  of 


lA'FLAMMA  TION.  69 

especial  value  in  chronic  inflammation.     In  deep-seated  in- 
flammation it  acts  as  a  counterirritant. 

Nitrate  of  silver  is  a  non-irritating  astringent  of  great  value 
in  inflammation  of  mucous  membranes.  It  forms  a  protective 
coat  of  coagulated  albumen,  and  is  much  used  in  treating  the 
throat,  mouth,  and  genital  organs. 

lehtJiyol  is  a  drug  of  decided  efficacy  in  reducing  inflam- 
matoiy  swelling.  It  is  usually  employed  in  ointments,  the 
strength  being  from  25  to  50  per  cent.  It  is  best  exhibited  with 
lanolin.  When  rubbed  in  over  the  glands,  the  joints,  and  in 
lymphatic  enlargements  it  is  of  great  value.  In  children  a 
25  per  cent.,  and  in  adults  a  50  per  cent.,  ointment  is  well 
rubbed  in  twice  a  day.  In  inflammatory  skin  disease,  syno- 
vitis, thecitis,  frost-bite,  bubo,  chilblain,  and  in  many  other 
conditions,  acute  or  chronic,  the  use  of  ichthyol  is  indicated. 
The  odor  of  ichthyol  is  highly  disagreeable,  and  when  ordered 
for  a  refined  person  it  had  better  be  deodorized.  For  this 
purpose  Hare  uses  oil  of  citronella,  TTLxx  to  5J  of  ointment. 

Mercurials. — Blue  ointment,  pure  or  diluted  to  various 
strengths,  is  valuable  to  a  high  degree.  It  is  spread  upon 
lint  and  kept  applied  over  chronically  inflamed  joints,  glands, 
tendons,  etc.  Blue  ointment  is  strongly  irritant,  and  will  soon 
blister  or  excoriate  a  tender  skin.  It  is  ver>'  beneficial  in 
periostitis,  and  is  employed  largely  in  chronic  inflammations. 

TJie  douche  consists  of  a  stream  of  water  falling  upon  a  part 
from  a  height.  The  water  may  be  poured  from  a  receptacle . 
or  may  run  through  a  tube,  and  may  either  be  hot  or 
cold.  Alternating  hot  and  cold  streams  are  very  popular  in 
chronic  inflammations  of  joints  and  tendons,  and  they  con- 
stitute the  "  Scotch  douche."  In  a  sprain  of  the  knee,  for 
instance,  where,  after  a  time,  thickening  has  occurred,  pour 
upon  the  part  daily,  from  a  height,  first  a  pitcherful  of  very 
hot  water,  then  a  pitcherful  of  very  cold  water ;  then  use 
friction  with  a  hand  greased  with  cosmoline.  The  douche 
acts  by  restoring  vascular  tone  and  by  promoting  the  action 
of  the  absorbents.  Hot  vaginal  douches  are  largely  employed 
in  pelvic  inflammations. 

Interniittoit  lieat  is  often  \Q.xy  useful.  In  a  sprained  and 
badly  swollen  ankle  much  relief  can  be  obtained  by  plunging 
the  foot  in  a  bucket  of  hot  water  several  times  a  day.  The 
part  is  put  into  water  as  hot  as  can  be  tolerated.  Every  few 
moments  some  very  hot  water  is  added.  This  gradual  ad- 
dition of  vt.xy  hot  water  permits  the  patient  to  stand  a  high 
degree  of  heat. 

Massage  is  a  procedure  not  frequently  enough  employed. 


70  MODERN  SURGERY. 

It  is  powerful  for  good  in  chronic  inflammations  at  the  period 
when  rest  is  abandoned.  It  acts  by  promoting  the  move- 
ments of  tissue-fluids  (blood,  lymph,  and  areolar  fluid),  stimu- 
lating the  absorbents,  strengthening  local  nervous  control, 
and  thus  improving  nutrition.  Passive  motion  in  joints  acts 
as  massage. 

Certain  agents  are  indicated  when  embryonic  tissue  exists 
in  large  amount  or  when  suppuration  exists  or  is  threatened, 
these  agents  being  the  various  forms  of  heat.  Heat  increases 
the  mobility  of  the  white  corpuscles,  increases  their  migra- 
tion, relieves  stasis  and  thus  diminishes  tension,  promotes 
tissue-change  and  cell-activity.  Continuous  heat  may  be 
used  early  in  an  inflammation,  as  in  the  first  stage  of  a 
pneumonia;  but  it  is  so  used  only  in  a  deep-seated  trouble, 
and  acts  purely  as  a  revulsive,  dilating  the  superficial  vessels 
and  helping  to  empty  the  deeper  ones.  Heat  is  often  used 
to  relieve  pain  and  without  any  other  purpose. 

The /(?r;«j-  of  heat  are — (i)  fomentations;  (2)  poultices; 
(3)  water-bath  ;  and  (4)  dry  heat. 

Fomentations. — A  fomentation  is  the  application  of  a  liquid 
to  the  surface  of  the  body  on  sponges  or  other  material. 
To  apply  a  fomentation,  wring  out  a  piece  of  flannel  in  hot 
water,  lay  it  upon  the  part,  and  cover  it  with  oiled  silk 
or  with  waxed  paper,  changing  it  as  soon  as  it  begins  to 
cool.  The  flannel  which  is  dipped  into  the  hot  liquid  is 
known  as  a  "  stupe."  The  turpentine  stupe  is  made  by 
wringing  out  the  flannel  as  above  and  then  putting  upon  it 
from  10  to  20  drops  of  turpentine.  Instead  of  fomenting 
the  part,  steam  may  be  thrown  upon  it.  Fomentations  are 
used  chiefly  for  their  reflex  influence  over  deep  congestions 
or  inflammations.  The  liquid  of  a  fomentation  may,  if  de- 
sired, contain  corrosive  subHmate,  carbolic  acid,  or  other 
agents.  Fomentations  are  very  useful  in  relieving  pain  in 
any  stage  of  an  inflammation  and  act  also  as  counter-irri- 
tants. 

Poultice  or  Cataplasm. — A  poultice  is  a  soft  mass  applied 
to  a  part  to  bring  heat  and  moisture  to  bear  upon  it.  Poul- 
tices can  be  made  of  ground  flaxseed,  of  slippery-elm  bark, 
of  arrowroot,  starch,  bread  and  milk,  potatoes,  turnips,  etc. 
To  make  a  flaxseed  poultice,  scald  a  spoon  and  a  tin  basin, 
put  the  flaxseed  into  the  dry  hot  basin,  and  pour  upon  it 
boiling  water  in  sufficient  quantity  to  form  a  thick  paste. 
The  proper  consistence  is  found  when  the  mass  would  stick 
if  it  were  thrown  against  a  wall.  It  is  now  spread  to  the 
thickness  of  a  quarter  of  an  inch  upon  a  piece  of  muslin,  and 


INFLA  MMA  TION.  7 1 

is  covered  with  a  bit  of  gauze  to  prevent  adhesion  to  the 
skin.  Flaxseed  retains  heat  a  long  time,  and  a  flaxseed  poul- 
tice needs  to  be  changed  only  every  five  or  six  hours.  The 
poultice  should  be  covered  outside  with  oiled  silk,  a  rubber- 
dam,  or  waxed  paper.  It  can  be  kept  very  warm  for  a  con- 
siderable period  by  placing  upon  it  a  bag  filled  with  hot 
water.  Spongiopilin,  when  moistened  with  hot  water,  is  a 
good  substitute  poultice.  Lint  soaked  with  hot  water  and 
covered  with  some  impermeable  material  does  very  well. 
The  fermented  poultice,  which  was  once  popular  for  gan- 
grenous ulcers,  was  made  by  sprinkling  yeast  upon  an  ordi- 
nary cataplasm.  The  charcoal  poultice  is  made  by  stirring 
charcoal  into  the  usual  poultice-mass.  A  poultice  containing 
opium  is  known  as  a  "  sedative  "  poultice.  About  gr.  ij  of 
opium  to  the  ounce  of  poultice-mass  relieves  pain.  An  an- 
tiseptic poultice  is  made  by  partly  wringing  out  gauze  in  a 
hot  solution  of  corrosive  sublimate  (i  :  looo),  covering  it 
with  oiled  silk,  and  placing  a  hot-water  bag  upon  it  to  main- 
tain the  heat.  The  antiseptic  poultice  or  fomentation  is  of 
great  service  in  removing  sloughs  from  foul  wounds  and 
ulcers.  It  is  the  only  form  of  poultice  which  is  admissible 
when  the  skin  is  broken.  Poultices  must  not  be  kept  on  too 
long,  as  they  will  then  vesicate,  especially  in  adynamic  con- 
ditions. If  a  poultice  is  found  to  be  vesicating,  stop  using  it 
or  sprinkle  it  with  powdered  oxid  of  zinc.  If  suppuration 
exists  or  is  seriously  threatened,  do  not  waste  time  by  using 
poultices,  but  incise  at  once.  If  suppuration  is  simply  threat- 
ened, incision  can  prevent  it  by  relieving  tension,  affording 
drainage,  and  permitting  of  the  local  use  of  antiseptics.  If 
pus  exists,  it  cannot  be  evacuated  too  soon.  To  use  poul- 
tices and  delay  incision  is  often  productive  of  irreparable 
harm.  After  incision  of  a  purulent  focus  it  is  often  useful  to 
apply  an  antiseptic  poultice. 

Water-bath. — The  continuous  hot  bath  is  now  rarely  em- 
ployed except  in  burns  and  cases  of  phagedena,  when  it  often 
proves  curative.  In  these  cases  an  antiseptic  agent  may  be 
dissolved  in  the  water.  Continuous  immersion  in  a  warm 
bath  is  used  by  some  surgeons  for  the  treatment  of  slough- 
ing wounds  and  large  purulent  areas. 

Dry  heat  is  applied  by  a  metallic  object  dipped  in  hot 
water  and  laid  upon  the  part ;  by  Leiter's  tubes,  through 
which  hot  water  flows ;  or  by  the  hot-water  bag.  Some 
surgeons  use  the  hot-water  bag  in  cases  of  mild  appendicitis 
in  order  to  favor  the  formation  of  adhesions.  The  hot-water 
bag  is  often  soothing  and  beneficial  when  laid   upon  an  in- 


72  MODERN  SURGERY. 

flamed  joint,  or  on  the  perineum  or  the  hypogastric  region 
in  cystitis.  A  bag  of  hot  sand,  a  hot  brick,  or  a  bottle  or 
can  of  hot  water  can  be  used  instead  of  the  bag. 

Irritants  and  Counteidrritants  in  Inflamtnation. — Irritants 
attract  an  increased  supply  of  blood  to  the  part  whereon 
they  are  applied,  and  are  used  for  their  local  effects. 
Co7interirritants  are  used  to  affect  by  reflex  influence  some 
distant  part.  In  chronic  inflammation  irritants  may  do  good 
by  promoting  the  blood-supply,  thus  favoring  the  removal 
of  exudates  (liniments  in  rheumatism  and  synovitis,  and 
nitrate  of  silver  in  ulcers).  Counter-irritants  are  powerful 
pain-relievers  when  used  over  an  inflamed  structure ;  they 
bring  blood  to  the  surface  and  cause  anemia  of  internal 
parts,  the  site  and  area  of  anemia  depending  on  the  site,  the 
area,  and  the  duration  of  the  surface-irritation.  To  strongly 
counterirritate  too  near  an  inflammation  is  harmful  instead 
of  beneficial.  (Do  not  blister  for  pericarditis  directly  over 
the  pericardium. — Brunton.)  Counterirritants  not  only  re- 
lieve pain  and  congestion  in  the  earlier  stages  of  inflamma- 
tion, but  they  also  promote  absorption  of  exudate  in  the 
later  stages.  This  is  seen  in  blistering  old  thickened  ulcers, 
and  in  painting  the  chest  with  iodin  to  relieve  pleuritic  effu- 
sion. Frictions,  besides  their  pressure-effects,  act  as  counter- 
irritants.  Frictions  may  relieve  skin-pain,  and  are  associated 
with  the  application  of  stimulating  liniments  in  the  treatment 
of  stiff  joints. 

There  is  no  more  efficient  method  of  relieving  pleural 
effusion  than  by  the  application  of  a  succession  of  blisters. 
Blisters  are  also  used  in  the  treatment  of  inflamed  joints, 
pericarditis,  pneumonic  consolidation  of  the  lung,  acute  and 
chronic  rheumatism,  etc. ;  and  are  applied  back  of  the  ears 
or  at  the  nape  of  the  neck  in  congestive  coma  or  meningitis. 
A  blister  can  be  produced  in  a  few  minutes  by  soaking  a  bit 
of  lint  in  chloroform,  and,  after  applying  it  to  the  surface, 
covering  it  with  oiled  silk,  and  then  with  a  watch-glass. 
Equal  parts  of  lard  and  ammonia  will  blister  in  five  minutes. 
It  is  easier  to  blister  with  cantharidal  collodion  or  blistering- 
paper.  Before  applying  a  blister,  shave  the  part  if  it  be 
hairy ;  then  grease  the  plaster  with  olive  oil  and  apply  it. 
Blistering  plaster  is  left  in  place  six  hours  in  the  case  of  an 
adult,  but  only  two  hours  in  the  case  of  an  old  person  or  a 
child ;  the  plaster  is  then  removed,  and  if  a  blister  has  not 
formed,  the  part  must  be  poulticed  for  a  few  hours.  When 
a  blister  is  obtained,  open  it  with  a  clean  needle.  If  it  be 
desired  to  heal  the  blister,  grease  it  with  cosmolin  or  with 


J  NFL  A  MM  A  7 /ON.  7  3 

zinc  ointment.  If  it  is  to  remain  open,  cut  away  the  stratum 
corneum  and  dress  with  cosmolin,  each  ounce  of  which  con- 
tains six  drops  of  nitric  acid. 

Pustulation  can  be  effected  with  tartar-emetic  ointment, 
with  the  hot  iron,  or  with  Vienna  paste.  Tartar-emetic  oint- 
ment was  formerl}'  used  on  the  scalp  in  meningitis.  To  pus- 
tulate with  the  hot  iron,  raise  the  iron  to  a  white  heat,  lay  it 
on  the  part,  remove  it  quickly,  apply  iced-water  cloths  for  an 
hour,  or  two,  and  then  employ  a  poultice.  The  hot  iron  is 
the  most  powerful  of  counter-irritants,  and  is  used  for  joint- 
inflammations,  bone-diseases,  and  inflammations  of  the  spinal 
cord.  Vienna  paste  consists  of  5  parts  of  caustic  potash 
and  6  parts  of  lime  made  into  a  paste  with  alcohol.  It  is 
applied  for  five  minutes,  and  is  then  washed  off  with  vinegar. 

Constitutional  Treatment  of  Inflammation. — Certain 
remedies  are  used  in  inflammation  for  their  general  or  con- 
stitutional effects;  these  remedies  are — (i)  general  bleeding; 
(2)  arterial  sedatives  ;  (3)  cathartics  ;  (4)  diaphoretics  ;  (5)  di- 
uretics ;  (6)  anodynes  ;  (7)  antipyretics  ;  (8)  emetics  ;  (9)  mer- 
cury and  iodids  ;  (10)  stimulants  ;  and  (11)  tonics. 

General  bleeding,  venesection,  or  pJilebotoniy,  is  suited  to  the 
early  stages  of  an  acute  inflammation  in  a  young  and  robust 
subject.  The  indication  for  its  employment  is  increased  arte- 
rial tension,  as  shown  by  a  strong,  full,  rapid,  and  incompress- 
ible pulse  in  a  vigorous  young  patient.  General  blood-let- 
ting diminishes  blood-pressure  and  increases  the  speed  of  the 
blood-current,  thus  amending  stasis,  absorbing  exudate,  and 
washing  adherent  corpuscles  from  the  vessel-wall ;  further- 
more, it  reduces  the  whole  amount  of  body-blood,  thus 
forcing  a  greater  rapidity  of  circulation,  decreases  the 
amount  of  fibrin  and  albumin,  lowers  the  temperature,  arrests 
cell-proliferation,  and  stops  effusion. 

This  procedure  was  in  former  days  so  highly  esteemed 
that  it  settled  into  a  routine  formula  to  be  applied  to  every 
condition  from  yellow  fever  to  dislocation.  The  terrible 
mortality  of  the  cholera  epidemics  from  1830  to  1835  led 
practitioners  to  question  the  belief  that  bleeding  was  a 
general  panacea,  and  from  this  doubt  there  w^as  born  in 
the  next  generation  violent  opposition  to  blood-letting  in 
any  disease.  Like  most  reactions,  opposition  has  gone  too 
far,  the  pendulum  of  condemnation  has  swung  be}-ond  the 
line  of  truth  and  sense,  and  thus  is  univ^ersally  neglected  or 
broadly  condemned  a  powerful  and  valuable  resource.  Many 
physicians  of  long  experience  have  never  seen  a  person 
bled;  its  performance  is  not  demonstrated  in  most  schools, 


74  MODERN  SURGERY. 

and  but  few  patients  and  families  will  permit  it  to  be  done. 
But  when  properly  used  it  is  beneficial.  It  is  only  appli- 
cable, however,  to  the  young,  strong,  and  robust,  and  not 
to  the  old,  weak,  or  feeble.  It  is  used  for  violent  acute  in- 
flammations of  important  organs  or  tissues,  and  not  for  low 
inflammations  or  for  slight  affections  of  unimportant  parts. 
It  is  used  in  the  early,  but  not  in  the  late,  stages  of  an 
inflammation.  It  is  used  when  the  pulse  is  frequent,  full, 
hard,  and  incompressible,  but  not  when  it  is  slow,  small, 
soft,  compressible,  and  irregular.  It  is  used  when  the  face 
is  flushed,  but  not  when  it  is  pallid.  It  is  not  used  in  fat 
persons,  drunkards,  very  nervous  people,  or  the  sufferers 
from  adynamic,  septic,  or  epidemic  diseases.  It  is  of  value 
in  some  few  cases  of  congestion  of  the  lungs,  pneumonitis, 
pleuritis,  meningitis,  prostatitis,  cystitis,  and  other  acute  in- 
flammatory conditions.     (See  Phlebotomy,  p.  y^}^ 

After  bleeding,  the  patient  should  be  put  upon  arterial 
sedatives,  diuretics,  diaphoretics,  anodynes,  and,  if  necessary, 
purgatives.  A  favorite  mixture  of  Prof.  S.  D.  Gross  was  the 
antimonial  and  saline,  consisting  of  gr.  xl  of  Epsom  salt, 
gr.  Y^^  of  tartar  emetic,  3  drops  of  tincture  of  aconite,  and  3j 
of  sweet  spirits  of  niter,  in  enough  ginger  syrup  and  water 
to  make  Iss ;  given  every  four  hours. 

Arterial  sedatives  are  of  great  use  before  stasis  is  pro- 
nounced ;  but  if  used  after  stasis  is  established,  they  will 
increase  it.  If  stasis  exists,  relieve  it  by  bleeding  before 
using  the  sedatives.  Either  local  bleeding  or  venesection 
abolishes  stasis  and  lowers  tension,  and  arterial  sedatives 
maintain  the  effect  and  hold  the  ground  which  is  gained. 
The  arterial  sedatives  employed  are  aconite,  veratrum  viride, 
gelsemium,  and  tartar  emetic.  These  sedatives  lessen  the 
force  and  the  frequency  of  the  heart-beats,  and  thus  slow 
and  soften  the  pulse,  and  are  suited  to  a  robust  person  with, 
an  acute  inflammation,  but  are  not  suited  to  a  weak  man  in 
an  adynamic  state. 

Aconite  is  given  in  small  doses,  never  in  large  amounts. 
One  drop  of  the  tincture  in  a  little  water  is  given  every  half 
hour  until  its  effect  is  manifest  on  the  pulse,  when  it  may  be 
given  every  two  or  three  hours.  Large  doses  of  aconite 
produce  pronounced  depression,  and  are  dangerous.  Aco- 
nite lowers  the  temperature,  slows  the  pulse,  and  produces 
diaphoresis. 

Veratrum  viride  is  a  powerful  agent  to  slow  the  pulse  and 
to  lower  blood-pressure ;  it  produces  moisture  of  the  skin, 
and  often  nausea.     It  is  given  in   i-drop  doses  of  the  tine- 


IXFLAMMA  TION.  J  5 

ture  every  half  hour  until  its  physiological  effects  are  mani- 
fested, when  the  period  between  doses  is  extended  to  two 
or  three  hours.  Ten  drops  of  laudanum  given  a  quarter 
of  an  hour  before  each  dose  of  veratrum  viride  will  prevent 
nausea. 

Giiscmuim  is  an  arterial  sedative  highly  approved  by 
Bartholow.  It  is  given  in  doses  of  5  to  10  drops  of  the 
tincture  every  three  or  four  hours. 

Tartar  emetic  lowers  arterial  tension  and  lessens  the  pulse- 
rate.  This  drug  is  not  largely  employed ;  if  it  is  used  with 
the  greatest  care,  it  is  no  better  than  some  other  agents,  and 
if  it  is  not  so  used  it  will  cause  dangerous  depression.  The 
dose  is  from  gr.  4q  to  gr.  -^-^  in  water  every  three  hours  until 
the  physiological  effects  are  manifest. 

Cathartics. — The  tongue  affords  the  chief  indication  for 
the  use  of  cathartics.  Treatment  in  an  inflammation  can  be 
inaugurated,  if  constipation  exists,  by  giving  a  cathartic. 
Castor  oil  can  be  given  in  capsules,  or  the  juice  of  half  a 
lemon  is  squeezed  into  a  tumbler,  i  ounce  of  oil  poured 
in,  and  the  rest  of  the  lemon  is  squeezed  on  top,  thus 
making  a  not  unpalatable  mixture.  Aloin,  podophyllum, 
the  salines,  and  calomel  in  5-  or  lo-grain  doses,  followed  by 
a  saline,  have  their  advocates.  In  peritonitis  the  salines  are 
of  unquestionable  value,  a  teaspoonful  of  Epsom  salt  and  a 
teaspoonful  of  Rochelle  salt  being  given  hourly  until  a  move- 
ment occurs.  In  the  course  of  inflammation,  from  time  to 
time,  if  there  be  constipation,  coated  tongue,  and  foul  breath, 
there  should  be  ordered  gr.  j  of  calomel  with  gr.  xxiv  of 
bicarbonate  of  sodium,  made  into  twelve  powders,  one  being 
given  every  hour ;  if  the  bowels  are  not  moved  by  the  time 
the  powders  are  all  taken,  a  saline  should  be  given.  If  a 
violent  purgative  effect  is  desired,  as  in  meningitis,  croton  oil 
or  elaterium  may  be  ordered.  If  constipation  is  persistent, 
give  fluid  extract  of  cascara  sagrada  daily  (20  to  40  drops), 
or  a  pill  at  night  containing  gr.  \  of  extract  of  belladonna, 
gr.  \  of  extract  of  nux  vomica,  gr.  -^-^  of  aloin,  gr.  \  of 
extract  of  physostigma,  and  gr.  ss  of  oil  of  cajuput.  Enemas 
or  clysters  may  be  used  in  some  cases.  A  very  useful 
enema  is  composed  of  fsj  of  oil  of  turpentine,  fsiss  of  olive 
oil,  f^ss  of  mucilage  of  acacia,  in  f5x  of  water.  Soap-suds 
and  vinegar  in  equal  parts  make  a  serviceable  clyster.  A 
combination  of  oil  of  turpentine,  castor  oil,  the  yolk  of  an 
&^%,  and  water  can  be  used.  Asafetida,  gr.  xxx  to  the  yolk 
of  one  Q%%,  makes  a  good  enema  to  amend  flatulence. 

Diaphoretics  are  very  useful.     A  good  sweat  in  the  start 


76  MODERN  SURGERY. 

of  an  acute  inflammation,  such  as  tonsillitis,  may  abort  the 
disease.  Dover's  powder  is  commonly  used,  but  pilocarpin 
is  preferred  by  some.  Camphor  in  doses  of  from  5  to  10 
grains  is  diaphoretic,  and  so  are  antimony  and  ipecac.  Ace- 
tate and  citrate  of  ammonium,  opium,  alcohol,  hot  drinks, 
heat  to  the  surface  (baths,  hot  bricks,  hot-water  bags),  ser- 
pentaria,  and  guaiac  are  diaphoretic  agents. 

Diuretics  are  useful  in  fevers  when  the  urine  is  scanty  and 
high-colored,  and  are  valuable  aids  in  removing  serous  effu- 
sions and  other  exudates.  Among  the  diuretics  may  be  men- 
tioned calomel  in  repeated  large  doses,  cocain,  caffein,  al- 
cohol, digitalis,  the  nitrites,  squill,  turpentine,  copaiba,  and 
cantharides.  The  liquor  potassae  and  the  acetate  of  potas- 
sium are  the  best  agents  to  increase  the  solids  in  the  urine. 
The  liquor  potassii  citratis  in  doses  of  fgij  to  fgiv  is  efficient. 
Large  draughts  of  water  wash  out  the  kidneys.  If  the  heart 
is  weak,  citrate  of  caffein  is  a  good  stimulant  diuretic. 

Anodynes  and  hypnotics  may  be  required.  Dover's  powder, 
besides  being  diaphoretic,  is  anodyne.  Opium  acts  well  after 
bleeding  or  purgation.  If  it  causes  nausea,  it  should  be  pre- 
ceded one  hour  by  gr.  xxx  of  bromid  of  potassium.  Opium 
is  used  by  the  mouth,  by  the  rectum,  or  hypodermatically. 
It  is  used  when  there  is  pain,  but  its  use  is  not  to  be  long  per- 
sisted in  if  it  can  be  avoided.  It  is  given  in  doses  measured 
purely  by  the  necessities  of  the  case.  If  opium  disagrees, 
try  the  combination  of  morphin  with  atropin.  After  an  ope- 
ration antipyrin  or  phenacetin  will  often  quiet  pain  and  secure 
sleep.  When  a  person  feels  "  so  tired  he  can't  sleep,"  alco- 
hol in  the  form  of  whiskey  or  brandy  must  be  given.  Sleep- 
lessness not  due  to  pain  is  met  by  chloral,  trional,  the  bro- 
mids,  or  sulphonal.  Chloral  is  dangerous  in  conditions  of 
weak  heart  or  exhaustion.  Bromids  must  be  given  in  large 
doses  to  be  efficient.  Sulphonal  must  be  given  about  four 
or  five  hours  before  sleep  is  expected,  in  doses  of  from  gr. 
X  to  gr.  XX  in  hot  milk  or  hot  mint-water.  Trional  is  safe 
and  very  satisfactory.  It  is  given  in  doses  of  gr.  xv  to  gr. 
XXV  in  hot  water. 

Antipyretics. — Diaphoretics,  purgatives,  and  arterial  seda- 
tives lower  temperature,  and  have  previously  been  alluded  to 
(p.  74).  There  are  two  great  classes  of  febrifuges — those 
which  lessen  heat-production  and  those  which  increase  heat- 
elimination.  In  the  first  group  we  find  quinin,  salicylic  acid 
and  the  salicylates,  kairin,  alcohol,  antimony,  aconite,  digitalis, 
cupping,  and  bleeding.  In  the  second  group  we  find  alcohol, 
nitrous  ether,  antipyrin,  acetanilid,  phenacetin,  opium,  ipecac. 


INFLAMMA  T/OX.  "JJ 

cold  to  the  surface,  and  cold  drinks.  In  surgical  inflammations 
it  is  rarely  necessary  to  employ  heroic  means  to  lower  temper- 
ature. The  use  of  such  an  agent  as  antipyrin  is  contraindi- 
cated  in  the  weak  and  adynamic,  and  it  is  never  to  be  thought 
of  as  a  means  of  lowering  temperature  unless  the  latter  goes 
above  103°.  Quinin,  in  doses  of  gr.  xx  to  gr.  xxx  given  at 
4  p.  M.,  may  prevent  an  evening  rise ;  salol  or  salicin  can  be 
given  during  the  day.  Inunctions  of  30  minims  of  guaiacol 
lower  the  temperature  in  tubercular  conditions  and  in  septic 
fevers.  These  inunctions  are  made  upon  the  abdomen,  and 
often  produce  surprising  results.  Dujardin-Beaumetz  main- 
tained that  fever  is  a  condition  in  which  the  organism  is  en- 
deavoring to  oxidize  and  render  inert  certain  poisonous  ma- 
terial, and  that  antipyretic  drugs  lessen  oxidation  and  actually 
make  the  patient  worse.  This  view  is  in  accordance  with  the 
experience  of  a  number  of  surgeons.  The  mere  discomfort 
of  fever  may  be  much  mitigated  by  antipyretic  drugs,  but  the 
fever-process  is  not  benefited  by  them. 

Euictics. — Emetics  may  do  good  when  the  patient  suffers 
from  a  parched,  coated  tongue,  a  dry  and  hot  skin,  nausea, 
and  gastric  oppression,  but  it  is  very  rarely  in  these  days  that 
we  employ  them.  There  can  be  used  .^j  of  alum  in  molasses, 
gr.  XX  of  sulphate  of  zinc,  or  a  tablespoonful  of  mustard  and 
a  teaspoonful  of  salt  given  in  warm  water  and  followed  by 
large  draughts  of  warm  water.  Ipecac  in  a  dose  of  gr.  xx 
can  be  employed.  The  emetic  dose  of  tartar  emetic  is  gr.  ij, 
but  it  is  too  depressant  a  drug  to  trifle  with.  The  sulphuret 
of  antimon\'  in  doses  of  from  i  to  5  grains  is  safe.  Apomor- 
phin  hypodermatically,  in  a  dose  of  from  gr.  -^-^  to  gr.  -|,  will 
act  in  five  minutes.  Emetics  are  valuable  in  inflammatory 
conditions  of  the  air-passages,  but  their  use  is  contraindicated 
in  diseases  of  the  heart,  brain,  and  bowels,  in  hernia,  in  dis- 
locations, in  fractures,  and  in  aneurysms. 

Mercury  and  the  lodids. — Mercury  is  an  alterative — that 
is,  an  agent  which  favorably  affects  body-nutrition  without 
causing  any  recognizable  change  in  the  fluids  or  the  solids 
of  the  body.  Mercury  lessens  blood-plasticity,  hinders  the 
exudation  of  liquor  sanguinis — thus  furnishing  less  food  to 
the  cells  in  the  perivascular  tissues — and  retards  the  forma- 
tion of  embryonic  tissue.  Further,  by  a  stimulant  action  on 
the  absorbents  it  promotes  the  breaking  up  of  an  existing 
inflammatory  exudate,  and  hence  limits  damage  from  excess 
of  embryonic  tissue.  The  time  at  which  mercury  is  best 
given  is  when  violent  symptoms  have  abated,  the  guide  being 
reduced  temperature  and  moist  skin.    It  is  often  given  in  con- 


78  MODERN  SURGERY. 

junction  with  the  local  use  of  sorbefacients  (the  acetate  of 
lead),  and  is,  when  possible,  associated  with  compression.  It 
is  sometimes  given  until  the  gums  are  slightly  touched,  but 
is  not  given  to  the  point  of  salivation.  When  the  breath 
becomes  offensive  and  the  gums  tender  on  snapping  the  teeth, 
or  when  griping  and  diarrhea  begin,  the  dose  should  be  re- 
duced. In  iritis  mercury  is  used  to  get  rid  of  the  plastic  ef- 
fusion which  is  causing  pupillary  fixation  and  opacity.  In 
keratitis  the  gums  should  be  touched  ligJitly.  In  orchitis, 
after  the  subsidence  of  the  acute  symptoms,  mercury  should 
be  employed.  In  pericarditis,  meningitis,  peritonitis,  and  in 
many  chronic  and  lingering,  and  in  all  syphilitic,  inflamma- 
tions this  drug  can  be  used. 

Some  persons  will  be  salivated  with  very  minute  doses  of 
mercury,  either  because  of  idiosyncrasy  or  previous  satura- 
tion. Others  can  take  enormous  doses  without  any  appre- 
ciable constitutional  effect.  The  action  of  mercurials  can  be 
favored  by  a  combination  with  ipecac  or  with  tartar  emetic. 
(For  salivation  see  p.  202). 

In  giving  mercury,  if  a  prompt  effect  is  desired,  give  gr.  iij 
of  calomel  every  three  hours  until  a  metallic  taste  is  noted 
in  the  mouth.  If  the  case  is  not  so  urgent,  gray  powder  is 
a  good  combination.  Children  are  given  calomel  and  sugar 
or  mercury  and  chalk.  If  it  is  desired  to  give  the  drug  for 
some  time,  corrosive  sublimate  is  a  suitable  form,  and  small 
doses  will  actually  increase  the  number  of  red  blood-cor- 
puscles. Corrosive  sublimate  is  to  be  given  alone  or  com- 
bined only  with  iodid  of  potassium.  The  green  iodid  of 
mercury  is  a  drug  suitable  for  prolonged  administration.  In 
the  prolonged  use  of  mercury  it  will  often  be  necessary  to 
give  at  the  same  time  a  little  opium  to  prevent  diarrhea  and 
griping.  A  rapid  effect  can  be  obtained  by  rubbing  with  a 
gloved  hand  .5j  of  the  oleate  of  mercury  or  3ss  of  the 
ointment  into  the  groins,  the  axillai,  or  the  inside  of  the 
thighs.  Suppositories  of  mercurial  ointment  induce  rapid 
ptyalism.  Hypodermatic  injections  of  corrosive  sublimate 
or  gray  oil  can  be  used,  and  must  be  thrown  deeply  into 
the  muscles  of  the  buttock.  Old  people,  those  who  are 
exhausted,  anemic,  and  broken  down,  and  the  scrofulous, 
bear  mercury  badly.  If  it  be  given  to  them  at  all,  it  must 
only  be  in  small  amounts  and  for  a  brief  time. 

Alkaline  iodids  are  useful  in  removing  the  products  of 
inflammation ;  they  can  be  given  for  a  long  time,  and  admir- 
ably supplement  mercurials.  Iodid  of  potassium  can  be  pre- 
scribed in  combination  with  corrosive  sublimate  as  follows  : 


IX FLA  MM  A  TION.  79 

R.   Ilydrarg.  chlor.  corros.,  gr.  ij ; 

Potass,  iodidi,  _^v  et  ^j  j 

Syr.  sarsaparill^  comp.,  q.  s.  ad  f5viij. — M. 
Sig.  f^ij,  in  water,  after  meals. 

lodid  of  potassium,  well  diluted,  is  given  on  a  full  stom- 
ach ;  it  is  never  given  concentrated  nor  before  meals.  A 
convenient  mode  of  administration  is  to  procure  a  concen- 
trated solution  of  the  iodid  of  potassium,  remembering  that 
every  drop  equals  gr.  i  of  the  drug,  and  giving  as  many- 
drops  as  may  be  desired  in  half  a  glass  of  water  after  meals. 
If  the  medicine  disagrees,  add  to  each  dose,  after  it  is  put  in 
water,  5j  of  the  aromatic  spirits  of  ammonia.  Extract  of  lic- 
orice is  a  good  vehicle  for  iodid.  If  the  mixture  in  water 
disagrees,  the  drug  should  be  given  in  milk.  Capsules  are 
satisfactory^  but  a  drink  ©f  water  should  be  taken  just  before 
and  again  just  after  taking  a  capsule,  to  protect  the  stomach 
from  the  concentrated  drug.  Iodid  of  sodium  may  agree 
when  iodid  of  potassium  does  not.  When  the  iodids  dis- 
agree they  produce  iodism.  The  first  indications  of  iodism 
are  a  bad  taste  in  the  mouth,  running  of  the  eyes  and  nose, 
and  sneezing,  followed  by  a  feeling  of  exhaustion,  absolute 
loss  of  appetite,  nausea,  tremor,  and  skin-eruptions  (acne, 
hemorrhages,  blebs,  hydroa,  etc.).  If  iodism  occurs,  stop 
the  drug  and  give  the  patient  Fowler's  solution  in  increas- 
ing doses,  laxatives,  diuretic  waters,  and  also  good  food  and 
stimulants  if  depression  is  great.  Sometimes  belladonna  does 
good  in  obstinate  cutaneous  disorders  induced  by  the  iodids. 

Remedies  Directed  Against  Special  Morbid  States. — If  in- 
flammation is  associated  with  rheumatism,  gout,  scurvy, 
syphilis,  tuberculosis,  or  any  other  constitutional  disease  or 
predisposition,  appropriate  treatment  should  be  instituted  to 
control  the  disease  or  combat  the  predisposition,  and  at  the 
same  time  the  area  of  inflammation  must  be  locally  treated. 
Syphilis  is  treated  by  the  internal  use  of  mercury  and  the 
iodids  ;  scur\'y,  by  vegetable  juices  and  potash  salts  ;  rheu- 
matism, by  the  alkalies  or  salicylates  ;  gout,  by  colchicum  or 
piperazin  ;  tuberculosis,  by  the  fats,  tonics,  and  an  open-air  life. 

The  use  of  alcoholic  stimulants  is  called  for  by  conditions 
rather  than  by  diseases,  being  indicated  by  the  state  of 
the  patient  rather  than  by  the  name  of  the  malady.  For 
a  brief  acute  inflammation  in  a  robust  young  person  alcohol 
is  not  needed  ;  but  all  who  are  weak  or  exhausted,  be  they 
young  or  old,  all  who  are  aged,  those  who  are  accustomed 
to  alcoholic  beverages,  those  who  have  high  temperatures  or 
failure  of  circulation,  and  those  who  labor  under  septic  in- 


8o  MODERN  SURGERY. 

flammations  or  adynamic  processes — require  alcohol  to  be 
given  with  a  free  hand.  In  an  acute  malady  a  feeble,  com- 
pressible, rapid,  or  irregular  pulse,  and  great  weakness  of  the 
first  sound  of  the  heart,  are  indications  that  alcohol  is  required. 
Low,  muttering  delirium  is  a  strong  indication.  There  is  no 
dose  of  alcohol  for  these  states :  it  is  given  for  its  effect.  Two 
ounces  may  be  needed  in  a  day,  or  perhaps  twenty  ounces. 
If  the  breath  of  the  patient  smells  strongly  of  the  alcohol, 
he  is  cretting-  too  much.  If  delirium  increases  after  each 
dose,  alcohol  is  doing  harm.  Alcohol  is  contraindicated  in 
acute  meningitis.  In  acute  illness  use  whiskey,  brandy, 
champagne,  or  alcohol  and  water.  During  convalescence 
there  may  be  used  a  little  spirit,  port,  claret,  or  sherry  wine, 
or  malt  liquor.  These  agents  will  promote  appetite,  diges- 
tion, and  sleep. 

Tonics  are  indicated  during  convalescence  from  acute  and 
throughout  the  course  of  chronic  inflammations.  There  may 
be  used  iron,  quinin,  and  strychnin  in  the  form  of  elixir ; 
iron  alone,  as  in  the  tincture  of  the  chlorid ;  quinin  in  tonic 
doses  (gr.  vj  to  gr.  viij  daily) ;  or  Fowler's  solution  of  arsenic. 
An  excellent  pill  consists  of — 

R.  Acid,  arsenos.  gr.  j ; 

Strychnin!,  gr.  ss ; 

Quinini,  gr.  xlviij ; 

P'erri  redact.,  gr.  vj. 
Ft.  in  pil.  No.  xxiv. 
Sig.  One  after  each  meal. 

Bitter  tonics  before  meals  improve  the  appetite.  One  of  the 
best  of  tonics  is  tincture  of  nux  vomica  in  gradually  increas- 
ing doses. 

Antiphlogistic  regimen  is  a  term  comprising  the  necessary 
directions  relating  to  diet,  ventilation,  cleanliness,  etc. 

Diet. — When,  in  the  early  stages  of  an  acute  inflammation, 
the  patient  cannot  eat,  there  must  be  administered  a  cathartic 
before  food  is  given.  Nausea  is  combated  with  calomel  and 
soda,  drop-doses  of  a  6  per  cent,  solution  of  cocain,  iced 
champagne,  iced  brandy,  chloroform-water,  hot  water,  cracked 
ice,  or  the  application  of  counterirritation  to  the  epigastric 
region.  When  the  process  is  depressive  from  the  start,  and 
in  any  case  after  the  earliest  stage,  feeding  is  of  vital  mo- 
ment. The  great  tissue-waste  calls  for  large  quantities  of 
nutritive  material,  but  the  impaired  digestion  demands  that 
the  food  shall  be  easily  assimilable;  hence  it  is  taken  in  liquid 
form,  small  quantities  being  frequently  given.  Milk  contains 
all  the  elements  required  by  the  body,  and  is  the  food  of  foods. 


I  NFL  A  MMA  TION.  8  I 

If  it  disagrees,  it  should  be  boiled  and  mixed  with  lime-water, 
or  to  each  dose  an  equal  amount  of  Vichy  or  soda-water  may- 
be added.  Peptonized  milk  is  a  valuable  agent.  One  part 
of  milk,  2  parts  of  cream,  and  2  parts  of  lime-water  make 
a  nutritious  and  digestible  mixture.  Milk  punch  is  largely 
used.  Whey  may  be  used  when  plain  milk  cannot  be  taken. 
Eggs  are  highly  nutritious,  but  are  apt  to  disturb  the  stom- 
ach ;  they  may  be  given  as  egg-nog,  or  simply  soft-boiled, 
or  the  yolk  can  be  beaten  up  in  a  cup  of  tea.  When  con- 
siderable nausea  exists  the  yolk  of  an  q^^  may  be  added 
to  5J  of  lemon-juice  and  sij  of  sugar,  the  glass  being  filled 
with  carbonated  water.  Beef  tea  is  certainly  a  stimulant, 
but  its  food-powers  are  questionable.  It  is  prepared  by  cut- 
ting up  one  pound  of  lean  beef,  adding  to  it  a  quart  of  water, 
and  then  simmering,  but  not  boiling,  down  to  a  pint,  finally 
filtering  and  skimming  the  liquid.  The  dose  is  a  wineglass- 
ful  seasoned  to  taste.  Meat-juice,  obtained  by  squeezing 
partly  cooked  meat  with  a  lemon-squeezer,  is  also  highly 
nutritious.  Liquid-beef  peptonoids  are  both  agreeable  and 
nutritious;  they  are  given  in  doses  of  Sss  to  sj.  Clam-juice 
is  palatable  and  digestible.  When  nothing  else  will  stay  on 
the  stomach  koumiss  will  often  be  retained.  This  fermented 
milk  is  nutritious,  stimulant,  and  very  useful.  Coffee  is  a 
valuable  stimulant  in  febrile  conditions.  If  the  stomach  re- 
tains no  food,  the  patient  must  be  fed  entirely  by  the  rectum. 
If  the  stomach  rejects  most  of  the  food  swallowed,  mouth- 
feeding  must  be  supplemented  by  nutritive  rectal  enemata. 
When  the  sufferer  feels  able  to  eat  a  little,  any  good  soup, 
strained  and  skimmed,  should  be  ordered.  As  the  patient 
gets  better  he  may  be  fed  on  sweetbreads,  chops,  etc.,  until 
he  gradually  reaches  ordinary  diet. 

Ventilation  and  Cleanliness. — The  ventilation  of  the  apart- 
ment is  of  the  greatest  importance.  Every  day  the  windows 
should  be  opened  widely  for  a  time,  the  patient  of  course 
being  protected.  When  the  windows  are  open  the  air  of  a 
room  can  be  quickly  changed  by  swinging  the  door  to  and 
fro.  A  constant  access  of  fresh  air  must  be  secured,  and 
the  temperature  kept  at  about  68°.  The  sick  man  must 
be  cleaned  and  be  sponged  off  with  alcohol  and  water  every 
day  if  high  fever  exists.  It  is  important  that  the  bed-cloth- 
ing be  clean  and  that  the  sheet  be  unwrinkled,  as  otherwise 
bed-sores  may  form. 

Chronic  Inflammation. — This  condition  progresses  slowly 
and  does  not  produce  symptoms  of  severity  either  in  the 
part  or  the  body  at  large. 

6 


82  MODERN  SURGERY. 

Causes. — Blood  diseases,  as  rheumatism  and  gout;  infec- 
tive diseases,  as  tuberculosis  and  syphilis ;  retained  pus  in  an 
ill-drained  abscess  ;  blockage  of  the  duct  of  a  gland  ;  foreign 
body  in  part ;  flow  of  an  irritant  secretion  (as  saliva  from  a 
fistula) ;  repeated  identical  traumatisms  of  an  occupation,  etc. 
W.  Watson  Cheyne  tells  us  it  is  not  due  to  the  ordinary 
pyogenic  organisms  (see  Cheyne's  article  in  Treves'  System 
of  Siirgery). 

Tissiie-clianges. — Practically  the  same  as  in  acute  inflam- 
mation, but  take  place  far  less  rapidly.  It  is  maintained  by 
Cheyne  and  others  that  typical  granulation-tissue  does  not 
form,  the  tissues  of  the  part  being  replaced  by  fibrous  tissue. 
The  amount  of  fibrous  tissue  produced  is  relatively  very 
great.  This  tissue  may  cause  permanent  thickening,  or  may 
contract,  and  thus  diminish  the  size  of  a  part.  Contraction 
is  very  considerable  in  cirrhosis  of  the  liver  and  in  inter- 
stitial nephritis. 

Symptoms. — Pain  varying  in  intensity  and  character ;  ten- 
derness ;  great  swelling,  which  in  some  cases  is  followed. by 
shrinking,  and  is  usually  indurated  or  brawny ;  sometimes  heat, 
rarely  discoloration  unless  the  skin  is  itself  inflamed.  There 
are  no  constitutional  symptoms  attributable  purely  to  the  in- 
flammation. If  there  are  such  symptoms,  they  are  due  to 
the  disease  which  induced  the  inflammation  or  to  interference 
with  the  function  of  an  organ  because  of  the  fibrous  mass. 
(For  treatment  of  chronic  inflammation  see  articles  upon 
special  regions  and  particular  structures.) 

IV.    REPAIR. 

Repair  is  an  active  process  by  which  destroyed  tissues 
are  replaced,  and  it  is  due  to  increased  nutritive  activity, 
rather  than  to  inflammation.  Inflammation  may  occur,  or  we 
may  be  obliged  to  induce  it  when  the  blood-supply  is  scanty 
or  the  exudation  deficient ;  but  certain  it  is  that  an  aseptic 
wound  heals  without  many  of  the  evidences  of  inflammation. 

Healing  by  First  Intention. — A  wound  may  heal  by 
"  first  intention."  This  mode  of  healing,  which  is  known 
as  "  primary  union,"  occurs  without  suppuration,  and  is 
observed  in  the  healing  of  an  aseptic  wound.  If  pus 
forms,  primary  union  will  not  take  place.  If  an  incised 
wound  is  asepticized,  the  hemorrhage  arrested,  and  the  edges 
brought  into  nice  apposition,  slight  swelling  arises,  but  no 
discoloration  appears.  Lymph  and  leukocytes  are  exuded 
from  the  vessels,  fibrin  forms  in  this  lymph,  and  the  edges 


e 


REPAIR. 


83 


of  the  wound  are  stuck  together  by  a  natural  cement.  In 
extensive  wounds  the  exudation  is  in  excess,  and  much  of 
it  must  be  drained  away,  for  its  retention  will  cause  ten- 
sion and  inflammation,  and  the  exudate  furnishes  a  favor- 
able soil  for  the  growth  of  pus  organisms.  The  exudation 
is  converted  into  embryonic  tissue  by  multiplication  of  its 
own  cells  and  multiplication  of  tissue-cells.  Embryonic 
tissue  consists  of  small  round  or  oval  cells  held  together 
by  a  jelly-like  intercellular  substance.  In  a  few  days  some 
spindle-shaped  cells  can  be  found,  and  also  large  cells  with 
one  or  more  nuclei  (epithelioid  cells).  Prolongations  of 
embryonic  tissue  are  raised  up  by  capillary  loops,  which 
prolongations  fuse  with  one  another  end  to  end,  or  fuse 
with  other  capillary  loops,  are  hollowed  out  and  become 
endothelial  tubes  or  capillaries.  By  vascularization  embry- 
onic tissue  becomes  granulation-tissue.  Granulation-tissue 
becomes  fibrous  tissue,  and  the  new  fibrous  tissue  contracts 
to  a  great  degree  (Figs.  25,  26).     The  final  step  in  healing  is 


'y 


^^tx 


. — Nuclei  developing  into 
fibers  (Bennett;. 


Fig.  26. — Cells  developing  into  fibers 
(Bennett). 


contraction  of  the  fibrous  tissue  and  the  covering  of  the  sur- 
face with  epithelium,  which  springs  from  the  epithelial  cells 
upon  the  edges.  This  final  process  is  called  "  cicatrization," 
and  consists  in  contraction  of  the  wound  and  skimming  over 
with  epithelium.  The  "  immediate  union  "  of  some  writers 
never  occurs.  This  term  means  the  union  of  microscopical 
parts  to  their  counterparts  without  any  effort  at  repair.  A 
first  union  is  effected  always  by  fibrin,  and  next  by  embryonic 
tissue.  A  wound  healing  by  first  intention  exhibits  no  evi- 
dence of  inflammation.  There  is  some  slight  tenderness,  but 
no  actual  pain.  A  certain  amount  of  swelling  arises  because 
of  exudation  of  fluid  from  the  blood,  and  the  coagulation  of 
this  fluid  makes  the  wound-edges  hard.  Venous  obstruc- 
tion  leads   in   some   cases  to  a  considerable  fluid  swelling. 


84  MODERN  SURGER  Y. 

During  the  first  twenty-four  hours  after  a  wound  begins  to 
heal  by  first  intention  the  discharge  is  most  plentiful,  but 
after  this  period  it  becomes  very  scanty  and  soon  ceases 
entirely,  and  can  be  much  diminished  in  quantity  in  the  first 
day  by  the  application  of  pressure.  In  a  large  wound  we 
notice  a  profuse  flow  of  bloody  serum.  Warren  says  that  after 
a  hip-joint  amputation  over  a  pint  flows  out  during  the  first 
twenty-four  hours.  In  a  large  wound  special  methods  to 
secure  drainage  are  required.  In  a  small  wound  drainage  is 
obtained  between  the  stitches.  The  use  of  irritant  germicides 
in  a  wound  greatly  increases  the  amount  of  discharge  and  ren- 
ders drainage  necessary  in  even  a  small  wound  for  the  first 
twenty-four  hours.  In  an  aseptic  wound,  as  a  rule,  one-half 
of  the  stitches  are  removed  on  the  fifth  or  sixth  day  and  the 
remainder  on  the  eighth  day,  but  for  two  weeks  more  the 
wound  should  be  rested  and  supported,  as  the  new  tissue  is 
not  very  resistant  to  infection.  Aseptic  fever  always  arises 
when  much  exudation  is  given  out,  and  is  due  to  the  ab- 
sorption of  aseptic  pyrogenous  material  (p.  87). 

Healing  by  Second  Intention. — In  a  wound  whose 
edges  cannot  be  approximated  a  great  gap  has  to  be  filled, 
and  this  is  accomplished  by  granulation.  This  process  is 
known  as  "  healing  by  granulation  "  or  "  second  intention." 
In  an  hour  or  so  after  the  infliction  of  such  a  wound  (it  may 
be  in  less  time)  the  raw  surface  is  covered  with  a  thin  glazed 
layer  of  coagulated  blood  and  exudate.  This  glaze  is  fibrin, 
which  soon  becomes  filled  with  leukocytes ;  underneath  this 
fibrin-coat  cell-proliferation  is  proceeding  and  embryonic  tis- 
sue is  forming.  The  wound-discharge  is  at  first  thin  and 
red,  but  in  a  few  days  becomes  purulent  and  so  profuse  as  to 
wash  away  the  discolored  fibrin-coat.  Granulations  are  now 
disclosed,  the  embryonic  tissue  being  lifted  up  in  countless 
points  by  capillary  loops.  When  these  loops  approach  the 
surface  contraction  begins  in  the  fibrous  tissue  in  the  depth 
of  the  damaged  area,  which  contraction  brings  the  edges  of 
the  wound  nearer  together  and  gradually  cuts  off  by  press- 
ure the  excessive  blood-supply  which  is  no  longer  needed. 
When  the  granulations  reach  the  surface,  epithelium  in  a 
thin  bluish  film  grows  from  the  epithelial  cells  at  the  edge 
and  covers  the  ulcer.  Cicatrization  is  contraction  plus  skin- 
ning over  with  epithelium.  Epithelium  can  only  spring 
from  the  wound-edges,  unless  there  be  some  epitheHal 
structural  remains  in  the  wound,  such  as  an  undestroyed 
papilla,  a  sweat-duct,  or  a  hair-follicle.  If  the  granulations 
rise  above  the  surface,  constituting  exuberant  granulations 


REPAIR.  85 

or  proud  flesh,  they  must  be  cut  off  or  burned  away  before 
epitheUum  will  grow  over  the  wound.  Pale  edematous  gran- 
ulations are  usual  in  tuberculous  processes,  and  if  they  form 
pressure  must  be  applied.  The  contraction  of  cicatrization 
results  from  the  conversion  of  granulation-tissue  into  fibrous 
tissue  (Figs.  25,  26).  Contraction  is  so  great  after  some 
wounds  as  to  cause  terrible  deformities.  This  is  notably 
the  case  after  burns,  whose  scars  or  cicatrices  contain  much 
elastic  tissue.  Coagulation-necrosis  of  a  superficial  layer  of 
granulation-tissue  produces  a  diphtheritic  membrane  or  aplas- 
tic lymph.  This  coagulation-necrosis  depends  on  capillary 
closure  or  lack  of  capillary  development,  the  embryonic  tis- 
sue dying  for  want  of  nutriment.  Ulcers  heal  by  second 
intention. 

Healing'  by  Third  Intention. — This  consists  in  the  union 
of  two  granulating  surfaces,  and  is  seen  in  the  union  of  col- 
lapsed abscess-walls.  The  surgeon  occasionally  seeks  to  ob- 
tain union  by  third  intention  by  approximating  two  granulat- 
ing surfaces.  In  subcutaneous  wounds,  if  aseptic,  healing  oc- 
curs without  suppuration.  First  a  blood-clot  fills  the  wound, 
exudation  occurs,  and  embryonic  tissue  forms  in  the  walls 
of  the  cavity,  embryonic  tissue  is  converted  into  granulation- 
tissue,  the  new  granulation-tissue  grows  into  the  clot,  which 
is  broken  up  and  absorbed,  and  fibrous  organization  and  con- 
traction of  the  new  tissue  take  place.  If  suppuration  occurs, 
an  abscess  forms.  Healing  under  an  aseptic  blood-clot  is 
healing  "  by  first  intention."  The  fibrous  tissue  of  a  scar 
arises  from  granulation-tissue,  which  itself  arose  from  embr>'- 
onic  tissue.  The  multiplication  of  connective-tissue  cells  may 
be  by  direct,  but  it  is  usually  by  indirect,  division. 

Cell-division. — Direct  cell-divisio?i  consists  in  division  of 
the  nucleus  followed  by  division  of  the  entire  cell. 

Indirect  cell-division,  or  karyokinesis,  shows  remarkable 
changes  in  the  neucleus.  The  membrane  of  the  nucleus 
disappears ;  the  nuclear  network  becomes  first  close  and 
then  more  open,  and  the  cells  become  round,  if  not  so  be- 
fore. The  network  of  the  nucleus,  now  consisting  of  one 
long  fiber,  takes  the  shape  of  a  rosette ;  next  it  takes  a  star- 
form — the  aster  stage ;  two  sets  of  V's  next  form — the  equa- 
torial stage  ;  an  equatorial  line  appears  and  widens,  and  each 
set  of  V's  retreats  toward  a  pole.  Thus  two  new  nuclei  are 
formed,  each  polar  V  passing  in  inverse  order  through  the 
previous  changes  of  shape,  and  the  protoplasm  of  the  orig- 
inal cell  collecting  about  each  nucleus  (Fig.  27). 

In  non-vascular  tissues,  such  as  cornea  or  cartilage,  the 


'86 


MODERN  SURGERY. 


wound  is  glued  together  by  fibrin,  the  exudate  having  come 
along  the  lymph-spaces  from  adjacent  vascular  areas.  Organ- 
ization occurs  by  multiplication  of  fixed  tissue-cells  and  leu- 
kocytes. Divided  muscle,  if  the  ends  are  widely  separated, 
unites  by  fibrous  tissue.  The  ends  of  a  divided  muscle,  if 
closely  approximated,  unite  by  fibrous  tissue,  which  becomes 
filled  with  muscle-fibres.  It  is  not  yet  definitely  known 
whether  these  fibres  arise  by  growth  from  the  muscle-cells 
of  the  ends  of  the  muscle,  or  by  metamorphosis  of  the  new 
connective  tissue.  Divided  nerve,  when  approximated,  can 
regenerate.  The  ends  are  first  united  by  new  connective 
tissue  ;  this  new  tissue  is  a  bridge  for  nerve-cells,  and  is  finally 
converted  into  nerve  by  the  growth  of  cells  from  both  the 


Fig.  27. — Forms  assumed  by  a  nucleus  dividing  (Green,  from  Flemming). 

central  and  distal  ends,  the  cells  finally  meeting.  If  the 
ends  are  not  approximated,  they  join  by  fibrous  tissue,  the 
distal  end  atrophies,  and  the  proximal  end  becomes  bulbous. 
The  above  view  is  entertained  by  Mayer  and  Eichhorst. 
Waller  holds  that  repair  is  effected  by  the  central  end  alone. 
When  a  tendon  is  divided  the  ends  retract,  and  the  sheath, 
as  a  rule,  becomes  filled  with  blood-clot.  The  blood-clot  is 
rapidly  removed,  embryonic  tissue  replacing  it.  This  new 
tissue  arises  from  the  sheath,  and  the  cut  ends  do  not  partici- 
pate in  the  process.  Granulation-tissue  is  formed;  this  is  con- 
verted into  fibrous  tissue,  and  after  a  time  the  fibrous  tissue 
becomes  true  tendon.  If  no  blood-clot  forms  in  the  sheath, 
the  walls  of  this  structure  collapse  and  adhere,  and  the  sep- 
arated tendon-ends  are  held  together  by  a  flat  fibrous  band 
formed  from  the  collapsed  sheath  (Warren's  Surgical  Pa- 
thology). When  a  bone  is  broken  a  large  blood-clot  forms 
in  the  medullary  canal,  between  the  broken  ends,  below  and 
outside  of  the  periosteum.     Granulation-tissue  replaces  the 


SURGICAL   FEVERS.  87 

blood-clot,  granulation-tissue  becomes  fibrous  tissue,  and  the 
fibrous  tissue  in  many  places  becomes  cartilaginous.  In  the 
second  week  lime-salts  begin  to  deposit  and  bone  forms  (p. 
333).  Cartilage  can  heal  as  cartilage,  but  usually  unites  by 
fibrous  tissue.  When  an  artery  is  ligated,  embryonic  tissue 
forms  in  and  around  it,  the  walls  soften  and  are  converted 
into  the  same  tissue,  vascularization  occurs,  fibrous  tissue 
forms  and  contracts,  and  the  artery  is  converted  into  a 
fibrous  cord.  An  ulcer  heals  in  the  same  manner  as  does  a 
wound  with  loss  of  substance — by  second  intention.  An 
abscess  heals  by  collapse  of  its  sides  and  their  adhesion  (by 
third  intention).  The  sides  are  embryonic  tissue,  which  is 
formed  into  granulations,  these  granulations  unite,  and 
organization  into  fibrous  tissue  takes  place. 

V.    SURGICAL  FEVERS. 

The  surgeon  encounters  fever  as  a  result  of  an  inflamma- 
tion or  an  aseptic  wound,  in  consequence  of  infection,  and  in 
certain  maladies  of  the  nervous  system.  It  is  important  to 
remember  that,  while  elevated  temperature  is  generally  taken 
as  a  gauge  of  the  intensity  of  fever,  it  is  not  a  certain  index. 
There  may  be  fever  with  subnormal  temperature  (as  in  the 
collapse  of  typhoid  or  pneumonia),  and  there  may  be  elevated 
temperature  without  true  fever  (as  in  certain  diseases  of  the 
nervous  system).  It  is  true,  however,  that  elevation  of  tem- 
perature is  almost  always  noted. 

The  essential  phenomena  of  fever,  according  to  Maclagan, 
are — (i)  wasting  of  nitrogenous  tissue;  (2)  increased  con- 
sumption of  water;  (3)  increased  elimination  of  urea;  (4) 
increased  rapidity  of  circulation  ;  and  (5)  preternatural  heat. 

Traumatic  fevers  follow  a  traumatism  and  attend  the 
healing  or  infection  of  a  wound.  The  forms  are — (i)  benign 
traumatic  fever  ;  (2)  malignant  traumatic  fever. 

Benign  traumatic  fever  is  divided  into  two  classes — the 
aseptic  and  the  septic.  There  is  but  one  form  of  aseptic 
fever,  the  post-operation  rise.  The  septic  benign  fevers  are 
surgical  fever  and  suppurative  fever.  The  malignant  trau- 
matic fevers  are  sapremia,  septic  infection,  and  pyemia.  In 
this  section  we  discuss  only  the  benign  fevers. 

Aseptic  fever  appears  after  a  thoroughly  aseptic  operation 
and  after  a  simple  fracture  or  a  contusion.  It  may  appear 
during  the  evening  of  the  day  of  operation  or  not  until  the 
next  day,  and  reaches  its  highest  point  by  the  evening  of  the 
second  day  (100°  to  102°).    This  elevation  is  spoken  of  as  the 


88  MODERN  SURGERY. 

"  post-operation  rise."  Besides  the  fever  there  are  no  obvious 
symptoms ;  the  patient  feels  first-rate,  sleeps  well,  and  often 
wants  to  sit  up ;  there  are  no  rigors  and  there  is  no  delirium. 
The  wound  is  free  from  pain  and  appears  entirely  normal. 
Blood  examination  shows  leukocytosis.  This  fever  is  due  to 
absorption  of  pyrogenous  material  from  the  wound-area,  the 
material  being  obtained  from  clot  or  inflammatory  exudate, 
or  from  both.  Many  observers  believe  that  the  pyrogenous 
element  is  fibrin-ferment,  which  is  absorbed  from  disintegrat- 
ing blood-clot  and  coagulating  exudate.  Warren  thinks  the 
fever  due  to  fibrin-ferment,  and  "  also  to  other  substances 
sHghtly  altered  from  their  original  composition  during  life." 
Some  have  asserted  that  the  fever  is  due  to  nervous  shock. 

Schnitzler  and  Ewald  have  recently  studied  aseptic  fever.^ 
These  observers  maintain  that  aseptic  fever  can  exist  when 
no  fibrin-ferment  is  free  in  the  blood,  that  fibrin-ferment  can 
be  free  in  the  blood  when  there  is  no  fever,  and  in  conse- 
quence that  fibrin-ferment  is  not  the  cause  of  the  elevation 
of  temperature.  They  rule  out  of  consideration  nervous 
shock  as  a  cause,  and  assert  that  a  combination  of  several 
factors  is  responsible,  nucleins  and  albumoses  which  are  set 
free  by  traumatism  being  looked  upon  as  the  most  active 
causative  agents.  The  presence  of  nuclein  in  the  blood  in 
aseptic  fever  is  indicated  by  leukocytosis  and  by  the  increase 
of  the  alloxur  bodies  (including  uric  acid)  in  the  urine.  The 
capacity  of  nucleins  and  albumoses  to  cause  fever  is  greater 
in  the  tubercular  than  in  the  non-tubercular.  The  diagnosis 
of  aseptic  traumatic  fever  is  only  made  after  a  careful  exam- 
ination has  assured  the  surgeon  there  is  no  obscure  or  hid- 
den area  of  infection. 

In  some  cases  an  aseptic  fever  may  appear  after  an  opera- 
tion, and  later  be  replaced  by  a  septic  fever.  If  the  tempera- 
ture remains  high  after  a  few  days,  or  if  other  symptoms 
appear,  the  wound  should  be  examined  at  once,  as  trouble 
certainly  exists. 

Traumatic  or  surgical  fever  is  seen  as  a  result  of  infected 
wounds  where  there  is  inflammation,  but  no  pus.  This  fever 
is  due  to  the  presence  of  fermentative  bacteria  in  the  wound 
and  the  absorption  of  their  toxic  products.  The  most  active 
and  commonly  present  organisms  are  those  of  putrefaction. 
Fever  ceases  as  soon  as  free  discharge  occurs,  and  its  appear- 
ance is  an  indication  for  instant  drainage.  The  temperature 
rises  pretty  sharply  in  a  day  or  so  after  the  operation,  ascends 

^  See  Archiv  filr  klinische  Medicin,  Bd.  liii.,  H.  3,  1896;  also  statement  of 
their  views  in  Medical  Record,  Dec.  19,  1896. 


SURGICAL   FEVERS.  89 

with  evening  exacerbations  and  morning  remissions,  and 
reaches  its  height  about  the  third  or  fourth  day,  when  sup- 
puration sets  in  ;  the  temperature  begins  to  drop  when  pus 
forms,  if  the  pus  has  free  exit,  and  reaches  normal  at  the  end 
of  a  week  (see  Suppurative  Fever).  Stitch-abscesses  are  often 
found  in  surgical  fever.  If  a  post-operation  rise  continues 
for  an  unnaturally  long  time,  or  if  after  it  has  passed  away  a 
secondary  rise  is  noted,  suspect  infection  and  examine  the 
wound.  The  wound  is  painful,  tender,  swollen,  discolored, 
and  often  foul.  The  stitches  must  be  cut,  and  the  area 
asepticized,  and  packed  with  iodoform-gauze  or  drained  by  a 
tube.  The  fact  that  this  fever  is  apt  to  cease  when  suppura- 
tion begins  led  the  older  surgeons  to  hope  for  pus  and  to 
endeavor  to  cause  it  to  form. 

Suppurative  Fever. — This  fever,  which  is  due  to  the  ab- 
sorption of  the  toxins  of  pyogenic  organisms,  occurs  after 
suppuration,  has  begun,  and  is  found  when  the  pus  has  not 
free  exit.  It  can  follow  or  be  associated  with  surgical  fever, 
or  may  arise  in  cases  in  which  surgical  fever  has  not  existed. 
Suppuration  in  a  wound  is  indicated  by  a  rapid  rise  of  tem- 
perature— possibly  by  a  chill.  The  skin  becomes  swollen, 
dusky  in  color,  and  edematous,  pain  becomes  pulsatile,  and 
much  tenderness  develops.  The  wound  must  at  once  be 
drained  and  asepticized.  In  a  chronic  suppuration,  such  as 
occurs  in  the  mixed  infection  of  a  tubercular  area,  there 
exists  a  fever  with  marked  morning  remissions  and  vesperal 
exacerbations,  attended  with  night-sweats,  emaciation,  diar- 
rhea, and  exhaustion.  This  is  known  as  "  hectic  fever ;"  it 
is  really  a  chronic  suppurative  fever.  The  treatment  of  hec- 
tic fever  consists  in  the  drainage  and  disinfection  if  possible, 
the  excision  of  the  infected  area,  the  employment  of  a  nutri- 
tious diet,  stimulants,  tonics,  remedies  for  the  exhausting 
sweats,  and  free  access  of  fresh  air. 

Other  Forms  of  Fever. — Fever  of  Tension. — When 
there  is  great  tension  upon  the  stitches  the  spots  where 
the  stitches  perforate  ulcerate  and  some  fever  arises.  To  re- 
heve  the  fever  of  tension  cut  one  or  several  stitches.  This 
fever  is  in  some  cases  surgical,  and  in  some  suppurative,  ac- 
cording as  to  whether  the  infective  organisms  cause  fermen- 
tation or  suppuration. 

Fever  of  Iodoform  Absorption  (p.  27). 

Malaria. — It  is  wise  to  examine  the  blood  in  supposed  sep- 
tic fevers,  for  only  by  this  means  can  malaria  be  excluded. 
It  is  more  common  to  mistake  sepsis  for  malaria  than  mala- 
ria for  sepsis. 


90  MODERN  SURGERY. 

Surgical  Scarlet  Fever. — It  is  maintained  by  some  writers 
(notably  Victor  Horsley  and  Sir  James  Paget)  that  a  child  is 
rendered  especially  susceptible  to  scarlet  fever  by  the  shock 
of  a  surgical  operation.  Scarlet  fever  which  develops  after 
an  operation  is  spoken  of  as  surgical  scarlet  fever.  Warren 
quotes  Thomas  Smith  as  having  had  ten  cases  of  scarlet  fever 
in  forty-three  operations  for  lithotomy  in  children.  The 
puerperal  state  is  supposed  also  to  predispose  to  scarlet 
fever.  Some  writers  hold  that  an  attack  of  scarlet  fever  after 
an  operation  is  a  coincidence.  Others  maintain,  and  with 
great  show  of  reason,  that  a  red  scarlatiniform  eruption  ap- 
pearing after  an  operation  rarely  indicates  genuine  scarlet 
fever,  but  usually  points  to  infection,  as  such  eruptions  are 
known  occasionally  to  arise  in  septicemia. 

Hoffa  has  discussed  this  subject  elaborately.  He  con- 
cludes that  four  types  of  eruption  can  follow  operation:  (i) 
a  vaso-motor  disturbance  due  to  irritation  of  sensory  nerves, 
and  manifested  by  a  transient  urticaria  or  erythema ;  (2)  a 
toxic  erythema  due  to  absorption  of  aseptic  pyrogenous  ma- 
terial from  the  injured  area — the  absorption  of  carboHc  acid, 
iodoform,  or  corrosive  sublimate,  or  the  effect  of  ether;  (3) 
an  infectious  rash  which  is  sometimes  found  in  septicemia  or 
pyemia,  and  due  to  minute  emboli  composed  of  bacteria, 
which  emboli  lodge  in  the  capillaries  ;  (4)  true  scarlet  fever, 
with  the  usual  symptoms  and  complications,  the  organisms 
having  entered  by  way  of  the  wound,  and  the  eruption  often 
beginning  at  the  wound-edges  (quoted  in  Warren's  Surgical 
Pathology). 

VI.   TERMINATIONS   OF   INFLAMMATION. 

Inflammation  may  terminate  in  a  return  of  the  part  to 
health  or  in  its  death.  Recovery  is  said  to  be  by  delitescence 
when  the  inflammation  is  arrested  at  an  early  stage,  and  by 
resolution  when  the  inflammation  passes  on  regularly  to  the 
formation  of  embryonic  tissue  and  this  tissue  is  absorbed. 
New  formation  is  the  termination  of  inflammation  when  there 
has  been  loss  of  substance  or  when  the  embryonic  tissue  is 
not  absorbed.  Death  of  a  part  is  by  suppuration  (molecular 
death)  or  gangrene  (molar  death). 

Inflammation  may  terminate  in — (i)  efllision  of  liquor  san- 
guinis ;  (2)  formation  of  embryonic  tissue ;  (3)  formation  of 
pus  ;  (4)  ulceration  ;  and  (5)  mortification. 

Diffusion  of  I/iquor  Sanguinis. — The  so-called  "  se- 
rum "  of  inflammation  is  not  serum  at  all,  but  is  Hquor  san- 


TERMINATIONS   OF  INFLAMMATION.  9 1 

guinis,  which  contains  few  cells  and  in  consequence  does  not 
tend  to  coagulate.  We  meet  with  true  serum  in  passive  con- 
gestions, but  not  in  active  inflammation.  Effusion  of  "  se- 
rum "  into  connective  tissue  constitutes  edema;  and  into  a 
sac,  like  the  peritoneum,  dropsy  ;  dropsy  being  designated  by 
the  prefix  hydro-,  as  hydrothorax.  Abdominal  dropsy  is 
ascites.  Anasarca  is  general  effusion  of  serum  resulting 
from  altered  blood-pressure.  Edema  is  made  manifest  by 
the  signs  of  inflammation,  the  swelling  being  soft,  smooth, 
and  inelastic,  and  the  parts  pitting  on  pressure.  Effusion  of 
blood  liquor  can  be  beneficial,  unloading  the  vessels  and 
hence  relieving  pain,  tension,  and  hyperemia.  P^ffusion  of 
blood  liquor  can  be  harmful.  In  connective  tissue  fluid  in 
great  quantity  can  cut  off  the  circulation  of  certain  areas, 
thus  causing  necrosis.  Effusion  into  a  cavity  causes  press- 
ure on  its  contained  parts  ;  for  instance,  in  a  hydrothorax 
the  lung  is  compressed. 

Treatment. — Edema  can  be  relieved  by  multiple  punctures  ; 
but  if  it  threatens  necrosis,  free  incisions  must  be  made.  If 
the  dropsy  be  considerable,  the  fluid  must  be  let  out  by  tap- 
ping, aspiration,  or  incision.  Tapping  must  be  done  as  asep- 
tically  as  cutting.  In  aspirating  use  full  aseptic  care.  When 
it  is  wished  to  drain  the  abdomen,  the  latter  should  be  opened 
with  a  knife,  because  an  intestine  might  happen  to  be  glued 
to  the  abdominal  wall,  and  when  not  detected  by  previous 
percussion,  a  trocar  or  a  needle  could  easily  perforate.  In 
a  moderate  edema  use  locally  compression,  and  tincture  of 
iodin  diluted  with  an  equal  bulk  of  alcohol.  In  persistent 
edema  employ  frictions  with  a  stimulating  liniment.  Inter- 
nally, salines  and  diuretics  are  indicated.  The  compound 
jalap  powder  is  well  suited  to  dropsies.  Mercurials  can  be 
used,  and  in  severe  cases  also  elaterium. 

Formation  of  Bmbryonic  Tissue. — The  term  "  lymph  " 
is  a  synonym  for  fibrinous  exudate,  coagulable  lymph,  plastic 
infiltrate,  indifferent  tissue,  or  embryonic  tissue.  Granulation- 
tissue  is  vascularized  lymph,  and  when  it  forms  inflammation 
has  passed  into  new  formation.  It  is  customary  to  speak  of 
new  formation  as  a  termination  of  inflammation,  but,  as  a 
matter  of  fact,  inflammation  has  ceased  when  it  begins.  New 
formation  is  discussed  in  the  section  upon  Repair.  In  in- 
flammation effusion  of  liquor  sanguinis  and  migration  of 
white  corpuscles  take  place,  fibrin  forms  in  the  exudate  and 
the  liquor  sanguinis  coagulates.  This  is  followed  by  pro- 
liferation of  the  corpuscles  and  of  the  fixed  connective-tissue 
cells   (Fig.    28).     Effused   liquor    sanguinis,   which    contains 


92 


MODERN  SURGERY. 


many  corpuscles  and  which  coagulates,  is  met  with  in  se- 
vere inflammation.  Lymph  may  be  absorbed  or  it  may  be 
organized  into  tissue.  If  it  becomes  organized,  capillaries 
form  in  it  by  the  extension  from  the  surrounding  tissue  of 
capillary  loops,  which  raise  up  the  lymph  and  form  granula- 
tions. A  granulation  may  be  defined  as  a  small  mass  of 
lymph  containing  vessels  (Fig.  29).  If  lymph  is  absorbed, 
it  is  taken  up  by  the  lymphatics. 

Lymph  is  divided  into  two  forms — plastic  or  foruiative 
lymph,  that  which  can  be  converted  into  tissue,  hence  that 
which  can  bring  about  repair ;  aplastic  or  croupous  lymph, 
that  which  develops  no  fibres  and  cannot  be  converted  into 
tissue,  and  which  in  consequence  cannot  bring  about  repair. 
Effusion  of  lymph  may  be  beneficial.  It  repairs  all  injuries ; 
it  surrounds  and  encapsules  foreign  bodies  ;  it  circumscribes 


Pig.  28. — Recent  lymph,  forming  false 
membrane  (Gross). 


Fig.  29. — Blood-vessels  in  granulation  (Gross) 


abscesses ;  and  it  often  prevents  pus  from  evacuating  into 
a  cavity,  gluing  together  structures  to  make  a  channel  and 
leading  the  pus  to  the  surface.  It  may  be  injurious.  It  forms 
adhesions  of  the  brain,  pleura,  peritoneum,  pericardium,  and 
joints ;  it  produces  opacity  in  the  cornea  and  adhesions  of 
the  iris ;  it  constitutes  the  false  membrane  of  the  larynx  or 
trachea ;  and  it  causes  stricture  of  the  urethra  and  thicken- 
ing of  organs. 

Treatment. — Locally,  employ  compression,  tincture  of 
iodin,  lead-water  and  laudanum,  alternating  hot  and  cold 
douches,  friction,  and  massage  ;  also  ichthyol  and  lanolin. 
Internally,  use  mercurials  and  iodid  of  potassium  or  tartar 
emetic.  S.  W.  Gross  recommended  the  following  mixture 
for  inflammatory  thickening : 


R.  Potassii  iodidi,  gr.  x; 

Hydrargyri  chloiidi  corrosivi,  gr.  j^g  ; 

Antimonii  et  potassii  tartratis,  gr.  J^. — M. 

Sig.  Three  times  a  day,  in  half  a  glass  of  water,  after  meals. 


TERMINATIONS   OF  INFLAMMATION.  93 

Suppuration  is  a  process  in  which  tissues  and  inflamma- 
tory exudates  are  Hquefied  by  the  action  of  pyogenic  organ- 
isms, and  it  is  a  common  termination  of  infective  inflamma- 
tion. Localized  suppurations  are  due  to  staphylococci ; 
spreading  suppurations,  to  streptococci.  Pyogenic  bacteria 
liquefy  exudate  by  peptonizing  it.  The  pyogenic  organisms 
are  very  irritant,  and  when  deposited  cause  inflammation ;  in- 
flammation leads  to  exudation,  but  the  exudate  cannot  coag- 
ulate because  it  is  peptonized  by  the  ferment  of  the  micro- 
organisms. If  an  area  of  embryonic  tissue  is  invaded  by  the 
p)'ogenic  micro-organisms,  it  is  promptly  peptonized.  Pep- 
tonized exudate  or  embryonic  tissue  is  called  pus.  In  in- 
flammations induced  by  staphylococci  granulation-tissue,  as 
a  rule,  forms  at  the  periphery  of  the  inflammation,  the  micro- 
cocci are  imprisoned,  and  the  process  is  circumscribed.  In 
inflammations  induced  by  streptococci  granulation-tissue 
rarely  forms  in  time  to  imprison  the  micro-organisms,  and 
the  suppuration  spreads  widely.  Suppuration  can  be  induced 
by  the  injection  of  pyogenic  bacteria,  by  their  entry  through 
a  wound,  and  by  rubbing  them  upon  the  skin.  In  some  rare 
instances,  especially  when  the  diet  has  been  putrid,  they  may 
enter  through  the  blood  and  lodge  at  a  point  of  least  resist- 
ance. The  entry  of  pyogenic  bacteria  does  not  necessarily 
cause  suppuration,  as  the  healthy  human  body  can  destroy 
a  considerable  number,  even  if  given  in  one  "  dose ;"  but  a 
large  number  in  a  healthy,  or  even  a  small  number  in  an  un- 
healthy, organism  almost  certainly  does.  The  pus  of  all  acute 
abscesses  contains  bacteria  of  suppuration,  but  the  pus  of 
tubercular  abscesses  does  not,  unless  there  be  a  mixed  in- 
fection ;  in  other  words,  pure  tubercular  pus  is  not  pus  at  all. 

Can  suppuration  be  induced  without  micro-organisms  ?  It 
is  true  that  the  injection  of  irritants  can  cause  the  formation 
of  a  thin  fluid  which  contains  no  organisms,  but  is  this  non- 
bacterial pus  really  pus  ?  The  same  sort  of  fluid  is  formed 
by  injecting  cultures  of  pus  cocci  which  have  been  rendered 
sterile  by  heat,  the  organisms  being  killed,  a  ferment  con- 
tained in  the  bacterial  cells  being  the  active  agent.  Spu- 
rious or  "  aseptic  "  pus  does  not  concern  us,  as  it  is  never 
found  practically.  Impaired  health  or  an  area  of  lowered 
vitality  predisposes  to  suppuration.  The  lymphatic  glands, 
medulla  of  bones,  serous  membranes,  and  connective  tissue 
are  especially  prone  to  suppurate.  When  a  medullary  canal 
suppurates  after  a  chill  to  the  surface  or  after  a  blow  that 
does  not  cause  a  wound,  we  know  that  the  organisms  must 
have  arrived  by  means  of  the  blood. 


94 


MODERN  SURGERY. 


Pus  may  form  in  twenty-four  hours  after  an  inflammation 
begins,  or  it  may  not  form  for  days.  The  older  surgeons 
claimed  that  pus  could  do  good  by  protecting  granulations 
and  separating  disorganized  tissue.  It  is  now  held  that  it  is 
absolutely  harmful  by  melting  down  sound  tissue  and  poi- 
soning the  entire  organism.  Modern  surgery  has  to  a  great 
degree  abolished  pus. 

If  pus  stands  for  a  time,  it  separates  into  two  portions — 
(i)  a  watery  portion,  the  liquor  puris  or  pus-serum,  contain- 
ing peptone,  fat,  microbic  products,  osmazone,  and  salts,  and 
not  tending  to  coagulate ;  (2)  a  solid  portion,  or  sediment  of 
micro-organisms  of  suppuration,  pus-corpuscles  (Fig.  30),  and 


Fig.  30.— Fragmentation  of  nucleus  in  leukocytes  undergoing  transformation  into  pus- 
corpuscles  (Senn). 

broken-down  tissue.  The  pus-corpuscles  are  either  white 
blood-cells  or  altered  connective-tissue  cells.  Some  of  them 
are  dead,  some  have  ameboid  movements,  some  are  fatty, 
others  are  granular  and  contain  more  than  one  nucleus,  and 
all  are  degenerating.  A  pus-cell  is  waste-matter,  and  it  can- 
not aid  in  repair. 

Forms  of  Pus. — Laudable  or  healthy  pus,  a  name  long  in 
vogue,  is  a  contradiction,  no  pus  being  healthy.  In  former 
days  free  suppuration  after  an  operation  was  regarded  as  a 
favorable  indication,  and  when  it  occurred  the  surgeon  con- 
gratulated himself  that  surgical  fever  was  at  an  end.     At  the 


TERMINATIONS   OF  INFLAMMATION.  95 

present  day  suppuration  after  an  operation  is  an  evidence  of 
previous  infection,  of  lack  of  care,  or  of  infection  by  the 
blood.  The  so-called  laudable  pus  is  seen  coming  from  a 
healing  ulcer,  and  is  a  yellowish-white  or  a  greenish  fluid  of 
the  consistence  of  cream,  opaque,  with  a  very  slight  odor  if 
it  is  not  putrid,  and  having  a  specific  gravity  of  about  1.030. 

Malignant,  zuatoy,  or  ichorous  pus  is  a  thin,  watery,  putrid 
fluid.     It  is  pus  filled  with  the  organisms  of  putrefaction. 

Sanious  pus  is  a  form  of  ichorous  pus  containing  blood 
coloring-matter  or  blood.  It  is  thin,  of  a  reddish  color,  and 
very  acrid,  corroding  the  parts  that  it  comes  in  contact  with. 
It  is  found  notably  in  caries  and  carcinoma. 

Concrete  or  fibrinous  pus,  which  contains  flakes  of  fibrin 
or  coagulated  fibro-purulent  masses,  is  met  with  in  serous 
cavities  (joints,  pleura,  etc.).  These  masses  are  found  in 
infective  endocarditis  (Bowditch). 

Blue  pns. — The  color  of  blue  pus  is  due  to  the  bacillus 
pyocyaneus. 

Orange  pus  is  due  to  the  action  of  sarcina  aurantiaca,  and 
appears  in  violent  inflammations. 

Serons  pus  is  a  thin  serous  fluid  containing  a  few  flakes. 

So-called  scrofulous  or  curdy  pus  is  not  pus  at  all,  unless 
the  tubercular  area  has  undergone  pyogenic  infection. 

So-called  gummy  pus  arises  from  the  breaking  down  of  a 
gumma  which  has  outgrown  its  own  blood-supply.  It  is 
not  pus. 

Muco-pus  is  found  in  purulent  catarrh — that  is,  in  suppura- 
tive inflammation  of  an  epithelial  structure.  It  contains  pus- 
elements  and  epithelial  cells. 

Caseous  pus  comes  from  the  fatty  degeneration  of  pus- 
corpuscles  or  inflammatory  exudations.  This  mass  may 
calcify.     It  occurs  especially  in  tubercular  processes. 

Contagious  pus  is  that  which  contains  and  conveys  the 
elements  of  some  specific  contagion,  such  as  small-pox  or 
a  chancroid. 

Suppuration  is  announced  by  the  intensification  of  all 
local  inflammatory  signs.  The  heat  becomes  more  marked, 
the  discoloration  dusky,  the  swelling  augments,  the  pain  be- 
comes throbbing  or  pulsatile,  and  the  sense  of  tension  is 
greatly  increased.  The  skin  at  the  focus  of  the  inflammation 
after  a  time  becomes  adherent  to  the  parts  beneath,  and  fluc- 
tuation soon  appears.  This  adhesion  of  the  skin  is  a  prepa- 
ration for  a  natural  opening,  and  is  what  is  known  as  "  point- 
ing." An  important  sign  of  pus  beneath  is  edema  of  the 
skin.     This  is  sometimes  noticeable  in  empyema  or  pyotho- 


96  MODERN  SURGERY.       . 

rax  and  in  appendicitis.  The  above  symptoms  can  be  rein- 
forced and  their  significance  proved  by  the  introduction  of 
an  aseptic  tubular  exploring-needle  and  the  discovery  of  pus. 
Irregular  chills,  high  fever,  and  drenching  sweats  are  very 
significant  of  suppuration  in  an  important  structure  or  of  a 
large  area. 

Diffused  Cellulitis  or  Phleg-monous  Suppuration ;  Puru- 
lent Infiltration. — This  process  may  involve  a  small  area  or 
an  entire  limb,  and  is  due  to  infection  by  the  streptococcus 
pyogenes  or  streptococcus  of  erysipelas.  It  is  announced  in 
severe  cases  by  enormous  swelling,  the  development  of  areas 
which  feel  boggy,  a  dusky-red  discoloration,  and  great  burn- 
ing pain.  Gangrene  of  superficial  areas  is  not  unusual.  The 
discharges  of  the  wound,  if  a  wound  exists,  are  apt  to  dry 
up,  and  the  wound  becomes  foul,  dry,  and  brown.  The 
adjacent  lymphatic  glands  are  much  enlarged.  The  patient 
has  chills,  sweats,  and  high  oscillating  temperature,  due  to 
suppurative  fever,  sapremia,  or  even  septic  infection  or 
pyemia.  Diffuse  suppuration  tends  to  arise  in  infected  com- 
pound fractures,  in  extravasation  of  urine,  and  after  the 
infliction  of  a  wound  upon  a  person  broken  down  in  health. 
It  is  not  unusual  after  scarlet  fever,  and  is  typical  of  phleg- 
monous erysipelas.  The  pus  is  sanious  and  offensive.  This 
diffused  suppuration  may  widely  separate  muscles,  and  even 
lay  bare  the  bones.  It  is  a  very  grave  condition,  and  may 
cause  death  by  exhaustion,  septic  intoxication,  septic  infec- 
tion, pyemia,  or  hemorrhage  from  a  large  vessel  which  has 
been  corroded.  CelluHtis  of  a  mild  degree  may  surround 
an  infected  wound  or  a  stitch-abscess.  Its  spread  is  mani- 
fested by  red  lines  of  lymphangitis  running  up  to  the  adja- 
cent lymphatic  glands.  Light  cases  may  not  suppurate,  the 
lymphatics  carrying  off  the  poison.  Any  case  of  cellulitis  is, 
however,  a  menace,  and  any  severe  case  is  highly  dangerous 
(see  Erysipelas). 

Acute  Abscesses. — An  abscess  is  a  circumscribed  cavity 
of  new  formation  containing  pus.  We  emphasize  the  fact 
that  it  is  a  circumscribed  cavity — circumscribed  by  a  mass 
of  embryonic  tissue.  A  purulent  infiltration  is  not  circum- 
scribed, hence  it  does  not  constitute  an  abscess.  An  essen- 
tial part  of  the  definition  is  the  assertion  that  the  pus  is  in  a 
cavity  of  new  formation,  in  an  abnormal  cavity ;  hence  pus 
in  a  natural  cavity  (pleural,  pericardial,  synovial,  or  perito- 
neal) constitutes  a  purulent  effusion,  and  not  an  abscess 
unless  it  is  encysted  in  these  localities  by  walls  formed  of 
inflammatory  tissue. 


TEHMIXATIOXS   OF  INFLAMMATION.  97 

An  acute  abscess  is  due  to  the  deposition  and  multiplica- 
tion of  pyogenic  bacteria  in  the  tissues  or  in  inflammatory 
exudates.  These  bacteria  attack  exudates  or  tissues,  form 
irritants  which  intensify  the  inflammation,  and  by  exerting  a 
peptonizing  action  on  intercellular  substance  and  fibrin  of 
the  exudate  liquefy  tissue  and  the  products  of  inflammation, 
and  form  pus.  As  a  rule,  within  twenty-four  hours  after 
lodgement  of  the  bacteria  the  exudation  increases  in  amount, 
the  migrated  leukocytes  gather  in  enormous  numbers,  the 
fibers  of  tissue  swell  up,  and  the  connective-tissue  spaces 
distend  with  cells  and  fluid.  The  connective-tissue  cells, 
acted  on  by  pus  cocci,  multiply  by  kar>'okinesis,  develop 
many  nuclei,  lose  their  stellate  projections,  degenerate,  and 
constitute    one   form  of  pus-corpuscle,   leukocytes  forming 


Fig.  31. — Infiltration  of  connective  tissue  of  cutis  (X  500),  with  beginning  suppuration  in  the 

center  (Senn;. 

the  other.  All  the  small  vessels  are  choked  with  leukocytes, 
this  blocking  serving  to  cut  off  nourishment  and  tending  to 
produce  anemic  necrosis.  Liquefaction  occurs  at  many  foci 
of  the  inflammation,  drops  of  pus  being  formed,  the  amount 
of  each  being  progressively  added  to  and  many  foci  coales- 
cing (Fig.  31).  The  pus-cavity  is  circumscribed,  not  by  a 
secreting  pyogenic  membrane,  but  b\'  embryonic  tissue 
whose  cells  and  intercellular  material  have  not  as  yet 
broken  down,  and  this  area  of  embryonic  tissue  is  circum- 
scribed by  a  zone  of  inflammation.  As  an  abscess  increases 
in  size  the  embr\'onic  tissue  from  within  outward  liquefies 
into  pus,  and  the  zone  of  inflammation  beyond  continually 
7 


9^8  MODERN  SURGERY. 

enlarges  and  forms  more  lymph.  After  a  time  the  inflam- 
mation reaches  the  surface,  the  embryonic  tissue  glues  the 
superficial  to  the  deeper  parts,  liquefaction  of  this  lymph 
occurs,  a  small  elevation  due  to  fluid  pressure  appears  (point- 
ing), and  this  elevation  thins  and  breaks  from  tension  and 
liquefaction  (spontaneous  evacuation).  When  an  abscess 
forms  in  an  internal  organ  or  in  some  structure  which  is 
not  loose  like  connective  tissue — for  instance,  in  a  lymphatic 
gland — a  mass  of  pyogenic  bacteria,  floating  in  the  blood  or 
lymph,  lodges,  and  these  bacteria  by  means  of  irritant  products 
cause  coagulation-necrosis  of  the  adjacent  tissue  and  inflam- 
matory exudation  around  it.  The  area  of  coagulation-necrosis 
becomes  filled  with  white  blood-cells,  and  the  dry  necrosed 
part  is  liquefied  by  the  cocci.  Suppuration  in  dense  struc- 
tures causes  considerable  masses  of  tissue  to  die  and  to  be 
cast  off",  and  these  masses  float  in  the  pus.  Death  of  a  mass 
with  dissolution  of  its  elements  is  necrosis  or  inflammatory 
gangrene.  An  abscess  heals  by  the  collapse  of  its  walls 
and  the  formation  of  an  abundance  of  granulation-tissue ;  in 
many  cases  the  granulations  of  one  wall  join  those  of  the 
other  side,  the  entire  mass  of  granulations  being  converted 
into  fibrous  tissue,  and  this  tissue  contracting  (healing  by 
third  intention).  If  the  walls  do  not  collapse,  the  abscess 
heals  by  second  intention. 

Forms  of  Abscesses. — The  following  are  the  various 
forms  of  abscesses  :  acute  or  phlegmonous,  which  follows  an 
,  acute  inflammation  ;  strumous,  cold,  lymphatic,  tubercular,  or 
\  chronic  abscess  is  due  to  tubercle,  and  does  not  contain  true 
pus  without  there  is  secondary  infection.  It  presents  no 
signs  of  inflammation.  A  lymphatic  abscess  may  form  in  a 
week  or  two,  and  hence  is  not  necessarily  chronic,  which 
term  may  also  be  used  to  mean  a  persistent  non-tubercular 
abscess ;  caseous  or  cheesy  abscess,  a  cavity  containing  thick 
cheesy  masses,  is  due  to  the  fatty  degeneration  of  exudate, 
and  most  commonly  results  from  the  caseation  of  a  tubercu- 
lar focus ;  circumscribed  abscess  is  one  limited  by  embryonic 
tissue ;  diffused  abscess  is  an  unlimited  collection  of  pus,  in 
reality  not  an  abscess,  but  either  a  purulent  effusion  or  a 
purulent  infiltration;  congestive,  gravitative,  wamiering,  or 
hypostatic  abscess  is  a  collection  of  pus  or  tubercular  mat- 
ter which  travels  from  its  formation-point  and  appears  at 
some  distant  spot  (as  a  psoas  abscess) ;  critical  or  consecutive 
abscess  is  one  which  arises  during  an  acute  disease ;  diathetic 
abscess  is  due  to  a  diathesis ;  embolic  abscess  is  due  to  an  in- 
fected embolus  ;  tympanitic  or  emphysematous  abscess  is  one 


TERMINATIONS   OF  INFLAMMATION.  ■  99 

which  contains  the  gases  of  putrefaction  ;  encysted  abscess,  in 
which  pus  is  circumscribed  in  a  serous  cavity ;  fecal  or  ste?'- 
coraceous  abscess  is  one  containing  feces  in  consequence  of  a 
communication  with  the  bowel ;  follicular  abscess  is  one  aris- 
ing in  a  follicle  ;  lieniatic  abscess  is  that  which  arises  around 
blood-clot,  as  a  suppurating  hematoma ;  marginal  abscess, 
which  appears  upon  the  margin  of  the  anus ;  pyemic  or 
metastatic  abscess  is  the  embolic  abscess  of  pyemia ;  7/iilk 
abscess  is  an  abscess  of  the  breast  in  a  nursing  woman  ; 
ossifluent  abscess,  arising  from  diseased  bone  ;  psoas  or  tuber- 
cular abscess,  arising  from  vertebral  caries,  following  the 
psoas  muscle  and  usually  pointing  in  the  groin  ;  sympathetic 
abscess,  arising  some  distance  from  the  excitinsr  cause,  such 
as  a  suppurating  bubo  from  chancroid,  is  not  in  reality  sym- 
pathetic, because  infective  material  has  been  carried  from  the 
primary  focus  ;  thecal  abscess  is  suppuration  in  a  tendon- 
sheath  ;  tropical  abscess  is  an  abscess  of  the  liver,  so  named 
because  it  occurs  chiefly  in  tropical  countries.  It  usually 
follows  dysentery ;  urinary  abscess,  caused  by  extravasated 
urine  ;  verminous  abscess,  one  which  contains  intestinal  worms 
and  communicates  with  the  bowel ;  syphilitic  abscess,  which 
occurs  in  the  bones  during  tertiary  syphilis  ;  Brodics  abscess 
is  a  chronic  abscess  of  a  bone,  most  common  in  the  head  of 
the  tibia  ;  superficial  abscess,  which  occurs  above  the  deep 
fascia ;  deep  abscess,  occurring  below  the  deep  fascia ;  and 
residual  or  Pagefs  abscess,  a  recurrence  of  suppuration,  it 
may  be  after  years,  about  the  residue  of  a  former  abscess. 

Symptoms  of  Acute  Abscess. — In  an  acute  abscess,  as 
before  stated,  a  part  becomes  inflamed  and  embryonic  tissue 
forms ;  this  is  liquefied  (as  above  noted)  and  pus  is  produced. 
If  the  abscess  is  in  the  brain,  in  the  tonsil,  or  in  the  neigh- 
borhood of  the  rectum,  the  odor  of  the  pus  is  apt  to  be 
offensive.  An  acute  abscess  can  occur  in  a  person  of  any 
constitution. 

Local  Symptoms. — Locally  there  is  intensification  of  in- 
flammatory signs  ;  swelling  enormously  increases,  the  dis- 
coloration becomes  dusky,  the  pain  becomes  throbbing  and 
the  sense  of  tension  increases,  the  cutaneous  surface  is  seen 
to  be  polished  and  edematous,  and  after  a  time  pointing  is 
observed  and  fluctuation  can  be  detected. 

Constitutional  Symptoms. — In  cases  of  small  collections 
of  pus  in  unimportant  structures  there  may  be  no  obvious  con- 
stitutional disturbance.  If  the  abscess  contains  much  pus  or 
affects  an  important  part,  generally  disturbances  appear,  from 
slight  rigors  or  moderate  fever  to  chills,  high  temperature, 


lOO  MODERN  SURGERY. 

and  drenching  sweats.  The  constitutional  condition  typical 
of  an  abscess  is  due  to  the  absorption  of  retained  toxins, 
and  is  known  as  "  suppurative  fever."  When  suppuration 
is  long  continued  there  exists  a  fever  which  is  markedly 
periodic :  the  temperature  rises  in  the  evening,  attaining  its 
highest  point  usually  between  4  and  8  p.  m.,  and  then  sinks 
to  normal  or  nearly  normal  in  the  early  morning  (from  4  to 
8  A.  M.).  When  the  temperature  begins  to  fall  profuse  per- 
spiration takes  place.     This  fever  is  known  as  "  hectic." 

The  symptoms  of  an  abscess  are  somewhat  modified  by 
location,  and  it  is  wise  to  discuss  acute  abscesses  in  different 
situations. 

Acute  Abscesses  in  Various  Regions. — Abscess  of  the 
brain  in  about  50  per  cent,  of  cases  results  from  suppurative 
disease  of  the  middle-ear.  In  abscess  of  a  silent  region  of  the 
brain  symptoms  may  long  be  entirely  absent.  The  usual 
symptoms  are  headache,  vomiting,  delirium,  drowsiness, 
optic  neuritis,  and  often  a  subnormal  temperature.  Local- 
izing symptoms  may  be  present.  In  but  few  cases  are  there 
fever  and  sweats  (p.  561).  In  extradural  abscess  there  is 
fever. 

Appendicinal  or  appendicular  abscess  results  from  inflam- 
mation, usually  with  perforation  of  the  vermiform  appendix, 
plastic  peritonitis  circumscribing  the  pus.  If  the  pus  is  not 
limited  by  adhesion,  the  peritoneum  is  attacked  by  diffuse 
septic  peritonitis  (p.  655).  The  signs  of  appendicular  abscess 
are  pain,  tenderness,  muscular  rigidity,  often  swelling,  dul- 
ness  on  percussion,  and  sometimes  fluctuation  and  skin- 
edema  in  the  right  iliac  fossa,  fever,  vomiting,  sometimes 
constipation,  and  sometimes  diarrhea. 

Abscess  of  the  liver  may  not  be  announced  by  symptoms 
until  rupture.  It  may  follow  dysentery,  may  be  a  result  of 
the  lodgement  of  infected  clots  from  the  hemorrhoidal  veins, 
or  may  follow  upon  the  pylephlebitis  of  appendicitis.  We 
usually  find  fever  of  an  intermittent  type,  profuse  sweats, 
pain  in  the  back,  the  shoulder,  or  the  right  hypochondriac 
region,  enlargement  of  the  area  of  liver-dulness,  also  hepatic 
tenderness,  and  finally  constitutional  symptoms  of  the  exist- 
ence of  pus.  Sometimes  there  are  fluctuation  and  skin- 
edema  over  the  liver,  and  the  general  cutaneous  surface 
may  be  a  little  jaundiced.  The  symptoms  vary  as  the  pus 
invades  adjacent  organs  (p.  660). 

Snbphrenic  abscess  is  apt  to  begin  beneath  the  diaphragm, 
though  in  some  few  instances  the  pus  forms  above  this  mus- 
cle, and  subsequently  gains  access  to  the  region  beneath.  This 


TERMINATIONS   OF  INFLAMMATION.  10 1 

abscess  may  contain  not  only  pus,  but  gas,  and  also  in  some 
cases  fluids  from  the  stomach  or  intestine.  It  may  arise  after 
perforation  of  the  bowel  or  stomach,  or  it  may  result  from 
Pott's  disease,  perinephric  abscess,  traumatism,  abscess  of  the 
liver,  kidney,  spleen,  or  pancreas,  empyema  or  pneumonia 
(Greig  Smith).  The  signs  are  pain,  fever,  sweats,  dyspnea, 
cough,  and  the  physical  signs  of  gas  in  the  cavity  of  the 
abscess. 

Abscess  of  the  hing  gives  the  physical  signs  of  a  cavity ; 
the  expectoration  is  offensive  and  contains  fragments  of  lung- 
tissue.  Pyemic  abscesses  may  exist  and  yet  escape  dis- 
covery. 

Abscess  of  the  niediasti)iuin  causes  throbbing  retrosternal 
pain,  chills,  fever,  sweats,  and  often  dyspnea.  A  tumor  may 
appear  which  pulsates  and  fluctuates,  but  the  pulsation  is  not 
expansile. 

Perinephric  abscess  usually  causes  tenderness  and  pain  in 
the  lumbar  region  or  about  the  hip-joint,  which  pain  runs 
down  the  thigh  and  is  accompanied  by  retraction  of  the  tes- 
ticle. Induration,  fluctuation,  or  edema  of  the  skin  may  ap- 
pear. The  constitutional  symptoms  of  suppuration  usually 
exist. 

Abscess  of  the  aiitniin  of  HigJivwre  causes  pain,  edema- 
tous swelling,  and  crepitation  on  pressure.  Pus  escapes  from 
the  nostrils,  and  a  rhinoscopic  examination  can  find  the  fluid 
passing  into  the  nares.  The  antrum  on  the  side  of  the  ab- 
scess cannot  be  transilluminated  by  an  electric  light  in  the 
mouth  (Garel's  sign). 

Abscess  of  the  larynx  induces  violent  cough,  pain,  interfer- 
ence with  the  voice,  swallowing,  and  breathing,  and  can  be 
seen  with  a  laryngoscope. 

Prostatic  abscess  is  manifested  by  chills,  fever,  and  sweats, 
developing  during  an  attack  of  acute  prostatitis. 

Abscess  of  the  breast  can  arise  from  absorption  of  pyogenic 
bacteria  from  a  fissure  or  abrasion  of  the  nipple.  Some  sur- 
geons maintain  that  the  bacteria  enter  along  the  milk-ducts, 
while  others  assert  that  they  gain  entry  by  the  lymphatics. 
It  is  most  common  in  nursing  women.  Its  symptoms  are 
pulsatile  pain,  dusky  discoloration,  skin-edema,  fluctuation, 
and  usually  constitutional  disorder. 

Suppurative  thecitis  or  felon  is  a  form  of  diffuse  suppura- 
tion (p.  5  I  2). 

Palmar  abscess  is  a  purulent  effusion  (p.  512). 

Furuncle  and  carbuncle  are  discussed  upon  pages  739  and 
740. 


102  MODERN  SURGERY. 

Empyema  is  a  purulent  effusion  (p.  605)  into  the  pleural 
sac.     It  is  technically  an  abscess  if  it  becomes  encapsuled. 

Diag-nosis. — The  diagnosis  of  an  abscess  rests  upon — (i) 
its  history;  (2)  fluctuation  ;  (3)  pointing ;  (4)  surface-edema ; 
and  (5)  the  use  of  the  tubular  exploring-needle. 

A  suspected  abscess  in  a  dangerous  or  important  part 
under  no  circumstance  should  be  opened  by  a  bistoury  with- 
out knowing  that  the  diagnosis  is  certainly  correct.  This 
knowledge  is  obtained  in  some  cases  by  inserting  a  small 
aspirating-needle  and  observing  the  nature  of  the  fluid  which 
exudes.  An  abscess  which  moves  with  the  pulse  because  it 
rests  upon  an  artery  may  be  confounded  with  an  aneurysm. 
The  pulse-movements  of  an  abscess  are  in  one  direction  only ; 
the  abscess  is  lifted  with  each  pulse-beat,  but  does  not  en- 
large, and  if  a  finger  is  laid  upon  either  side  of  it  the  fingers 
will  be  lifted,  but  not  separated.  The  pulse-movements  of 
an  aneurysm  are  in  all  directions  ;  they  are  pulsatile,  the  tu- 
mor grows  larger,  and  the  fingers  will  not  only  be  lifted,  but 
will  also  be  separated.  The  tubular  exploring-needle  can  be 
used  in  doubtful  cases ;  if  aseptic,  it  will  do  no  harm  even  to 
an  aneurysm.  Many  able  surgeons  object  to  the  employ- 
ment of  a  grooved  exploring-needle,  on  the  ground  that 
when  plunged  into  infected  areas  and  withdrawn  the  track 
of  the  penetration  becomes  infected  by  the  fluid  which  es- 
capes. A  rapidly  growing,  small-cell  sarcoma  feels  not  unlike 
an  abscess ;  but  the  exploring-needle  discovers  blood,  and 
not  pus.  A  cystic  tumor  is  separated  from  an  abscess  by 
the  absence  of  inflammation,  or,  if  it  inflames,  by  the  nature 
of  the  contained  fluid.^  Ordinary  caution  will  prevent  us 
from  confounding  an  abscess  with  strangulated  hernia.  A 
tubercular  abscess  is  separated  from  an  acute  abscess  by  the 
absence  of  inflammatory  signs  in  the  former. 

Prognosis. — The  prognosis  varies  according  to  the  num- 
ber of  abscesses,  their  location  and  size,  and  the  strength  of 
the  patient. 

Treatment. — In  the  treatment  of  an  abscess  there  is  one 
absolute  rule  which  knows  no  exception,  namely,  that  when- 
ever and  wherever  pus  is  found  the  abscess  should  be  evac- 
uated at  once,  and,  after  evacuating  it,  thorough  drainage 
provided  for.  It  should  be  opened  early,  if  possible  even 
before  pointing  or  fluctuation,  to  prevent  tissue-destruction, 
subfascial  burrowing,  and  general  contamination.  Drainage 
is  continued  until  the  discharge  becomes  scanty,  thin,  and 
seropurulent. 

Abscess   of  the  liver  requires  that  an   incision  be  made 


TERMINATIONS   OF  INFLAMMATION.  .  I03 

along  the  edge  of  the  ribs  down  to  the  liver,  which  organ 
is  then  stitched  to  the  edges  of  the  wound.  In  a  day  or 
two  after  the  first  operation  the  two  layers  of  peritoneum 
are  firmly  adherent  and  the  abscess  can  be  opened  without 
danger  of  the  passage  of  pus  into  the  peritoneal  cavity. 
The  abscess  is  opened  and  washed  out,  and  a  tube  inserted. 
Surgeons  occasionally  try  to  locate  the  pus  by  the  use  of  an 
aspirator  before  doing  the  cutting  operation  (p.  660).  Abscess 
of  the  liver  is  occasionally  reached  by  resecting  a  rib,  open- 
ing the  pleural  sac,  and  incising  the  diaphragm  (transthoracic 
hepatotomy).  Abscess  of  the  mediastinum,  like  all  other 
abscesses,  requires  incision  and  drainage.  This  is  most  eas- 
ily effected  by  trephining  the  sternum.  In  abscess  of  the  lung 
an  incision  is  made  and  the  pleura  is  exposed.  The  incision 
is  usually  through  an  intercostal  space ;  but  if  the  spaces  are 
narrow,  it  will  be  necessary  to  resect  a  rib.  If  the  two  layers 
of  pleura  are  found  adherent,  the  operation  is  proceeded  with. 
If  they  are  not  adherent,  they  are  stitched  together  with  a  cat- 
gut suture,  and  the  surgeon  waits  48  hours  before  continuing. 
The  operation  is  completed  by  locating  the  pus  by  means 
of  an  aspirator,  evacuating  it  by  the  cautery  at  a  dull  red 
heat,  and  inserting  a  drainage-tube  into  the  abscess-cavity 
(p.  607).  In  abscess  of  the  antrum  bore  a  gimlet-hole 
through  the  superior  maxillaiy  bone  above  the  canine  tooth, 
or  perforate  the  bone  by  means  of  a  trocar.  Irrigate  daily 
with  boiled  water  or  normal  salt  solution.  Keep  the  open- 
ing from  contracting  by  inserting  a  small  tent  of  iodoform 
gauze.  In  persistent  cases  it  may  be  necessary  to  draw 
a  tooth,  break  through  the  socket  into  the  antrum,  and  in- 
sert a  silver  or  hard-rubber  tube.  In  very  persistent  cases 
osteoplastic  resection  of  a  portion  of  the  upper  jaw  will  be 
demanded.  In  appendicular  abscess  incise,  support  abscess- 
walls  with  gauze,  in  many  cases  do  not  remove  the  appendix, 
and  insert  a  drainage-tube  and  strands  of  gauze  (p.  653). 

In  abscess  of  the  breast  make  an  incision  radiating  from 
the  nipple,  or,  what  is  better,  incise  under  the  breast  by 
means  of  a  cut  at  the  inferior  thoracic  mammary  junction,  and 
enter  the  abscess  from  beneath.  In  abscess  of  the  brain  the 
skull  should  be  trephined,  the  membranes  incised,  and  the 
abscess  sought  for,  opened,  and  drained  (p.  562).  In  an  ordi- 
nary superficial  abscess,  after  cleansing  the  parts,  make  the 
skin  tense,  incise  with  a  sharp-pointed  curved  bistoury,  and 
let  the  pus  run  out  itself,  pressure  being,  as  a  rule,  unde- 
sirable. If  tissue-shreds  block  up  the  opening,  they  must 
be  picked  out  with  forceps.     If  the  atmospheric  pressure 


I04  MODERN  SURGERY. 

will  not  cause  the  pus  to  flow  out,  make  light  pressure  with 
warm,  moist,  aseptic  sponges.  After  the  pus  has  come  away 
wash  the  cavity  with  peroxid  of  hydrogen  and  then  with 
corrosive  solution  (i  :  looo),  and  pack  with  iodoform  gauze 
for  two  or  three  days,  when  the  discharge  becomes  serous. 
Pursue  rigid  antisepsis  in  dealing  with  pus.  It  is  true  we 
already  have  infection,  but  infection  can  take  place  with  or- 
ganisms of  putrefaction,  causing  pus  to  become  putrid,  or 
with  other  bacteria. 

In  a  deep  abscess,  or  an  abscess  situated  near  important 
vessels,  do  not  boldly  plunge  in  a  knife.  Hilton  says  to 
"  plunge  in  a  knife  is  not  courageous,  as  it  is  without  danger 
to  the  surgeon,  but  may  be  fatal  to  the  patient."  Remember 
also  that  a  large  amount  of  pus  displaces  normal  anatomical 
relations.  Hilton's  method  of  opening  a  deep  abscess  (as  in 
the  axilla  or  neck)  is  to  cut  to  the  deep  fascia,  nick  the  fascia 
with  a  knife,  and  then  push  into  the  abscess  a  grooved  director 
until  pus  shows  in  the  groove ;  along  the  groove  push  a  pair 
of  dressing-forceps,  shut ;  after  they  reach  the  depths  upon 
them  and  withdraw,  and  so  dilate  the  opening ;  then  insert 
a  tube  and  irrigate.  In  an  abscess  in  the  posterior  part  of 
the  orbit,  after  incising  transversely  a  portion  of  the  upper 
lid,  the  abscess  should  be  reached  by  this  method.  Always 
endeavor  to  open  an  abscess  at  its  most  dependent  part,  re- 
membering that  the  situation  of  this  part  may  depend  upon 
whether  the  patient  is  erect  or  recumbent.  If  we  do  not 
make  the  opening  at  the  lowest  point,  all  the  pus  will  not 
run  out  and  the  walls  will  not  completely  collapse.  A  deep 
abscess  must  be  drained  thoroughly  until  the  discharge  be- 
comes seropurulent.  When  the  tube  is  removed  it  is  wise 
to  insert  a  tent  of  iodoform  gauze  just  through  the  outlet  of 
the  abscess.  This  tent  prevents  the  skin  from  closing  over 
the  channel.  It  is  reinserted  every  day  until  it  becomes 
clear  that  there  is  no  longer  danger  of  fluid  becoming 
blocked  and  retained.  When  an  abscess  contains  diverticula 
or  pouches,  they  should  be  slit  up  or  a  counter-opening 
ought  to  be  made.  A  counter-opening  is  made  by  entering 
the  dressing-forceps  at  our  first  incision,  pushing  them 
through  the  abscess  to  the  point  where  we  wish  to  make  our 
counter-opening,  opening  the  blades,  and  cutting  between 
them  from  without  inward.  The  blades  are  then  closed  and 
projected  through  the  incision  ;  they  are  opened  to  dilate 
the  new  door,  and  closed  again  upon  a  drainage-tube  which 
is  pulled  through  from  opening  to  opening  as  the  instrument 
is  withdrawn.     When  pus  burrows,  insert  a  grooved  director 


TERMIXATIONS    OF  INFLAMMATION.  I05 

in  each  channel  and  sht  the  sinus  with  a  knife.  An  abscess 
may  make  an  opening  through  dense  fascia,  the  opening 
being  small  like  the  neck  of  an  hour-glass  (shirt-stud  ab- 
scess). Always  examine  to  see  if  such  a  condition  exists, 
and  if  it  is  found,  incise  the  fascia. 

Rest  is  of  the  first  importance  in  the  healing  of  an  abscess, 
and  we  try  to  obtain  it  by  bandages,  splints,  and  pressure, 
which  will  immobilize  adjacent  muscles  and  approximate 
the  abscess-walls.  If  an  abscess  is  slow  to  heal,  use  as  a 
daily  injection  peroxid  of  hydrogen  followed  by  i  :  1000 
corrosive  sublimate,  or  3  drops  of  nitric  acid  to  .^j  of  water, 
or  3  grains  of  zinc  sulphate  to  5j  of  water,  or  a  5  per  cent, 
solution  of  carbolic  acid,  or  a  2  per  cent,  aqueous  solution 
of  pyoktanin,  or  20  drops  of  tincture  of  iodin  to  7,]  of  water  or 
a  solution  of  bichlorid  of  palladium.  Peroxid  of  hydrogen  is 
a  dangerous  agent  to  inject  into  the  cavity  of  a  deep  abscess 
of  the  neck,  as  the  liberated  gas  may  not  escape  from  the 
opening,  but  may  pass  widely  into  the  tissues  and  cause  great 
distention.  The  author  saw  a  child  who  narrowly  escaped 
death  after  such  an  injection.  In  this  patient  the  gas  passed 
beneath  the  pharyngeal  mucous  membrane  and  the  swelling 
almost  occluded  the  air-passages.  The  constitutional  treat- 
ment of  an  abscess  depends  upon  its  severity  and  upon  the 
importance  of  the  structures  involved.  In  a  bad  case  the 
patient  should  be  put  to  bed,  opiates  given  with  a  free  hand, 
the  bowels  kept  active  by  calomel  and  salines,  skin-activity 
maintained,  nutritious  food  insisted  on,  and  stimulants  liber- 
ally employed. 

Purulent  Effusions. — See  Suppurative  Thecitis,  Palmar  Ab- 
scess, Suppurative  Synovitis,  Purulent  Peritonitis,  Empyema, 
etc. 

Tubercular  abscess,  called  also  chronic,  cold,  scrofu- 
lous, and  lymphatic,  is  an  area  of  disease  produced  by  the 
action  of  the  bacilli  of  tubercle  and  circumscribed  by  a  dis- 
tinct membrane.  Ashhurst  says  that  the  term  "  chronic  "  is 
a  bad  one.  "  It  refers  etymologically  only  to  time.  A 
phlegmonous  abscess,  if  deeply  seated,  may  be  of  slower 
development  than  a  chronic  or  cold  abscess  which  is  super- 
ficial." A  tubercular  abscess  is  most  common  in  the  lym- 
phatic glands,  bones,  joints,  and  subcutaneous  connective 
tissues,  and  is  rare  after  the  twentieth  year.  It  may  contain 
quarts  of  curdy  pus.  The  bacilli  of  tubercle  cause  inflam- 
mation, and  granulation-tissue  is  formed,  which  in  the  centre 
undergoes  coagulation-necrosis  and  caseation,  and  at  the  pe- 
riphery is  converted  into  fibrous  tissue.     The  irritation   of 


I06  MODERN  SURGERY. 

toxins  produces  the  exudation,  and  anemia  due  to  the  mass 
outgrowing  its  own  blood-supply  is  the  cause  of  the  case- 
ation. First,  there  forms  from  granulation-tissue  a  cheesy- 
matter,  which  is  liquefied  into  scrofulous,  curdy,  or  tubercular 
fluid.  This  really  is  not  pus,  as  the  tubercle  bacillus  is  not 
pyogenic ;  if  true  pus  forms,  it  is  because  of  a  secondary 
infection  with  pus  cocci — an  accident,  and  not  a  part  of  the 
natural  process  of  formation  of  a  cold  abscess.  A  cold 
abscess  may  be  absorbed,  or  may  become  encapsuled  by 
densely  fibrous  organization  of  its  limiting-wall  into  a  thick 
pyogenic  membrane.  The  fibrous  wall  of  a  tubercular  ab- 
scess is  lined  by  a  thin,  yellowish  membrane,  which  is  stud- 
ded with  miliary  tubercles  (Volkmann's  membrane).  Tuber- 
cular matter  rarely  invades  a  muscle,  whereas  syphilis  often 
attacks  muscle  (Warren). 

Symptoms. — The  term  cold  abscess  is  employed  for  a 
tubercular  abscess  because  it  presents  no  inflammatory  signs. 
There  is  no  local  heat ;  no  discoloration  unless  pointing 
occurs  ;  the  parts  look  paler  than  natural ;  pain  is  absent  in 
the  abscess,  though  it  may  exist  at  the  point  of  origin  of  the 
fluid ;  the  tubercular  material  often  wanders  from  its  point 
of  origin  under  the  influence  of  gravity ;  fluctuation  is  pres- 
ent unless  thick  walls  mask  it.  Constitutional  symptoms 
are  trivial  or  absent  unless  secondary  infection  occurs.  The 
swelling  may  suddenly  appear  in  some  spot — the  groin,  for 
instance.  When  it  appears  suddenly  it  has  travelled  from  a 
distant  and  older  area  of  disease.  The  abscess  may  last  for 
years  without  producing  pain  or  annoyance.  The  tubular 
exploring-needle  will  settle  the  diagnosis.  The  constitution 
is  invariably  below  normal  because  of  the  tubercular  infec- 
tion, and  the  temperature  is  a  little  above  normal.  A  cold 
abscess  which  is  infected  with  pus  organisms  exhibits  great 
inflammation,  and  septic  fever  rapidly  develops.  In  tuber- 
cular disease  of  the  vertebrae  the  fluid  may  find  its  way  to 
the  lumbar  region,  to  the  iliac  region,  or  to  the  immediate 
neighborhood  of  Poupart's  ligament,  above  or  below  it. 

Tubercular  Abscesses  in  Various  Regions. — Tu- 
bercular abscess  of  the  head  of  a  bone  (Brodie's  abscess) 
arises  in  the  cancellous  structure  of  a  long  bone,  most  often 
in  the  head  of  the  tibia.  Pain  is  continued  but  not  usually 
very  severe,  is  of  a  boring  character,  and  is  worse  when  the 
patient  is  in  bed.  Attacks  of  synovitis  arise  from  time  to  time 
in  the  adjacent  joint.  There  is  no  such  thing  as  an  acute  ab- 
scess of  bone.  A  pyogenic  inflammation  of  such  severity 
that  it  would  cause  an  acute  abscess  in  soft  parts,  in  bone 


TERMINATIONS   OF  INFLAMMATION.  107 

causes  acute  necrosis.  The  organism  obtains  access  to  the 
bone  by  means  of  the  blood,  and  finds  in  the  bone  a  point 
of  least  resistance. 

Retropharyngeal  or  postpharyngeal  abscess  is  usually 
due  to  caries  of  the  cervical  vertebrae,  but  can  arise  in  the 
connective  tissue  of  the  parts  or  as  a  tubercular  adenitis. 
An  abrasion  of  the  mucous  membrane  may  admit  the  bacilli 
to  the  tissue  or  the  glands.  A  swelling  projects  from  the 
posterior  pharyngeal  wall,  and  there  is  great  interference 
with  respiration  and  deglutition.  Caseous  matter  from  caries 
of  the  cervical  vertebrae  may  reach  the  posterior  mediastinum 
by  following  the  esophagus,  or  it  may  appear  in  front  of  or 
behind  the  sternomastoid  muscle  (Edmund  Owen). 

Dorsal  Abscess. — The  tubercular  matter  in  dorsal  ab- 
scess arises  from  dorsal  caries,  flows  into  the  posterior  medi- 
astinum, and  reaches  the  surface  by  passing  between  the 
transverse  processes.  The  tubercular  matter  from  dorsal 
caries  may  run  forward  between  the  intercostal  muscles  or 
between  these  muscles  and  the  pleura,  pointing  in  an  inter- 
costal space  at  the  side  of  the  sternum  or  by  the  rectus 
muscle.  It  may  open  into  the  gullet,  windpipe,  bronchus, 
pleural  sac,  or  pericardium.  It  may  descend  to  the  dia- 
phragm and  travel  under  the  inner  arcuate  ligament  to  form 
a  psoas  abscess,  or  under  the  outer  arcuate  ligament  to  form 
a  lumbar  abscess.  A  psoas  abscess  points  external  to  the 
femoral  vessels,  a  characteristic  which  distinguishes  it  at  once 
from  a  femoral  hernia. 

Iliac  abscess  arises  from  lumbar  caries,  the  swelling  lying 
in  the  iliac  fossa  and  pointing  above  Poupart's  ligament. 

Psoas  abscess  is  usually  due  to  lumbar  caries,  the  fluid 
pointing  in  Scarpa's  triangle  external  to  the  femoral  vessels. 
A  psoas  or  iliac  abscess,  by  following  the  lumbosacral  cord 
and  great  sciatic  nerve,  forms  a  gluteal  abscess.  These 
abscesses  may  open  into  the  bowel,  bladder,  ureter,  or  peri- 
toneal cavity. 

Lumbar  Abscess. — In  a  lumbar  abscess  the  fluid  produced 
by  dorsal  caries  descends  beneath  the  outer  arcuate  liga- 
ment, or  the  fluid  from  lumbar  caries  which  collected  ante- 
rior to  or  in  the  quadratus  lumborum  muscle  passes  between 
the  last  rib  and  iliac  crest  in  the  triangle  of  Petit,  the  small 
space  bounded  by  the  crest  of  the  ilium,  the  posterior  edge 
of  the  external  oblique  muscle,  and  the  anterior  edge  of  the 
latissimus  dorsi  muscles.^ 

^  For  a  lucid  description  of  these  abscesses  see  Owen's  Manual  of  Anatomy, 
from  which  much  of  the  above  is  condensed. 


I08  MODERN  SURGERY. 

Chronic  abscess  of  the  breast  is  a  caseated  area  of  tu- 
berculosis of  the  breast.  A  lump  is  detected  which  slowly 
enlarges  and  finally  ruptures,  sinuses  being  formed.  The 
axillary  glands  are  apt  to  be  implicated.  The  patient  be- 
longs to  a  tubercular  stock,  as  a  rule  gives  a  history  of 
previous  tubercular  troubles  of  various  sorts,  and  has 
usually  borne  children.  Chronic  abscess  of  the  breast 
causes  little  or  no   pain. 

Treatment. — If  a  small  cold  abscess  exists  in  a  superficial 
structure,  open  it  with  aseptic  care,  rub  its  walls  with  bits 
of  gauze  to  remove  tubercular  masses,  irrigate  with  i  :  looo 
mercurial  solution,  pack  with  iodoform-gauze,  and  dress  anti- 
septically.  When  the  discharge  becomes  thin  and  scanty 
the  packing  can  be  dispensed  with.  If  it  be  slow  in  healing, 
inject  or  swab  out  with  a  stimulating  fluid  as  in  acute  abscess, 
or  inject  with  iodoform  emulsion. 

Chronic  Abscess  of  Bone. — Make  an  incision  to  bare  the 
bone.  Open  the  abscess  with  the  trephine,  the  gouge,  or 
the  chisel ;  curet  with  a  sharp  spoon  and  gouge ;  cut  away 
the  edges  of  the  bone  with  rongeur  forceps ;  irrigate  the  cav- 
ity with  hot  corrosive  sublimate  solution  (i  :  lOOo),  and  swab 
it  out  with  gauze  wet  with  pure  carbolic  acid ;  pack  with 
iodoform  gauze  and  apply  dry  antiseptic  dressings.  It  is 
better  not  to  employ  an  Esmarch  apparatus.  Bleeding  will 
not  be  severe,  and  when  no  apparatus  is  used  we  can  be  sure 
that  all  the  diseased  bone  has  been  removed,  because  sound 
bone  bleeds  and  dead  bone  does  not. 

Cold  Abscess  of  Lymphatic  Glands. — In  non-exposed 
portions  of  the  body  the  capsule  should  be  incised  and  dis- 
sected or  scraped  away,  and  the  cavity  swabbed  out  with 
pure  carbolic  acid  and  packed  with  iodoform  gauze.  If  the 
abscess  is  allowed  to  burst,  it  will  make  an  ugly  scar ;  there- 
fore in  exposed  portions  of  the  body  an  effort  should  be 
made  to  prevent  a  scar.  When  only  a  little  caseated  matter 
exists  and  the  skin  is  not  discolored,  prepare  the  parts  anti- 
septically  and  carry  a  silk  thread  by  means  of  a  needle 
through  the  skin,  through  the  gland,  and  out  at  its  lowest 
point.  Dress  with  gauze.  In  three  days  the  thread  can  be 
taken  out  and  a  firm  compress  applied.  When  the  gland  is 
almost  entirely  broken  down  and  the  skin  above  it  is  purple 
and  thin,  insert  a  hypodermatic  needle  through  sound  skin 
into  the  abscess,  draw  off  the  pus,  and  inject  iodoform  emul- 
sion (lo  per  cent,  of  iodoform,  90  per  cent,  of  glycerin  or 
olive  oil).  This  procedure  is  to  be  repeated  when  pus  again 
accumulates.     By  this  means  we  can  often  effect  a  cure  in 


TERMINATIONS   OF  INFLAMMATION.  IO9 

a  week  or  so.  When  an  abscess  breaks  or  is  at  the  point 
of  breaking  cut  away  all  purple  skin,  curet  the  abscess- 
walls  (the  abscess  having  become  a  scrofulous  ulcer), 
remove  the  remains  of  gland  and  capsule,  swab  the  cavity 
with  pure  carbolic  acid,  and  dress  with  iodoform  and  corro- 
sive gauze. 

Tubercular  glands  ought  to  be  extirpated  before  they 
caseate  and  form  abscess. 

Cold  Abscess  of  Mammary  Gland. — Many  operators 
simply  incise,  curette,  pack  with  iodoform  gauze,  and  dress 
antiseptically.  It  is  wiser  to  remove  the  entire  gland  and 
clean  out  the  axilla,  in  order  to  prevent  both  recurrence  and 
dissemination. 

Large  Cold  Abscesses  (Psoas  Abscess). — In  view  of  the 
facts  that  these  abscesses  may  cause  no  trouble  for  years 
and  that  an  operation  may  be  fatal,  some  eminent  surgeons 
are  opposed  to  an  operation  unless  the  abscess  is  moving 
toward  inevitable  rupture  or  is  disturbing  the  functions  of 
organs  by  pressure.  Most  practitioners  believe,  however, 
that  this  mass  of  tuberculous  matter  is  a  source  of  danger 
through  being  a  depot  of  infective  organisms  which  may 
overwhelm  the  system,  and  that  death  will  rarely  occur  in 
the  hands  of  the  operator  who  employs  with  intelligence 
strict  antisepsis.  In  no  other  cases  is  attention  to  every 
detail  more  important,  as  a  mixed  infection  can  easily  take 
place,  and  will  probably  mean  death. 

In  many  cases  aspiration  can  be  employed  to  empty  the 
cavity,  injecting  either  a  10  per  cent,  iodoform  emulsion 
to  the  amount  of  siij,  or  5iij  of  a  5  per  cent,  ethereal  solu- 
tion of  iodoform  after  the  fluid  is  sucked  out.  After  inject- 
ing the  emulsion  squeeze  and  manipulate  the  fluid  into  every 
nook  and  cranny.  The  American  Text-book  of  Surgery 
advises  the  injection  of  from  i  to  3  ounces  of  the  following 
preparation:  iodoform,  10  parts;  glycerin,  20;  mucil.  gum 
Arab.,  5  ;  carbolic  acid,  i  ;  water,  lOO. 

Whatever  fluid  is  chosen,  the  operation  must  be  repeated 
three  or  four  times  at  intervals  of  four  weeks.  It  is  danger- 
ous to  inject  large  amounts  of  iodoform,  as  poisoning  may 
be  produced  (p.  27).  Some  surgeons  incise  such  an  abscess, 
inject  iodoform  emulsion,  and  sew  up  without  drainage. 
Such  a  procedure  often  fails  and  is  sometimes  followed  by 
iodoform-poisoning.  If  aspiration  and  injection  fail,  open, 
under  rigid  antisepsis,  the  most  dependent  portion  of  the 
abscess,  scrape  its  wall  with  bits  of  gauze,  and  over-distend 
with  a   I  :  1000  solution  of  warm  corrosive  sublimate.     Let 


no  MODERN  SURGERY. 

the  mercurial  solution  run  out  and  then  irrigate  the  cavity 
with  hot  normal  salt  solution,  which  will  remove  the  re- 
mains of  the  corrosive  fluid.  With  a  long  probe  find  the 
highest  point  of  the  cavity,  and  make  a  counter-opening; 
scrape  well,  search  for  and  remove  carious  bone,  flush  out 
the  whole  area  with  corrosive  sublimate,  wash  out  the  mei- 
curial  solution  with  hot  normal  salt  solution,  inject  emul- 
sion of  iodoform,  and  either  make  tube-drainage  from  open- 
ing to  counter-opening  and  from  bone  to  counter-opening, 
or  pack  the  entire  cavity  with  iodoform  gauze.  If  hemor- 
rhage is  severe,  after  injecting  with  hot  salt  solution  the  cav- 
ity must  be  packed.  When  a  large  abscess  breaks  of  itself, 
it  should  at  once  be  drained  and  asepticized  as  above.  In 
the  treatment  of  a  cold  abscess  give  nutritious  food,  cod-liver 
oil,  quinin,  iron,  and  the  mineral  acids.  Removal  to  the  sea- 
.side  is  often  indicated,  and  mechanical  appliances  may  be 
needed  for  diseases  of  the  bones  and  joints.  If  secondary 
infection  does  occur,  the  patient  develops  hectic  fever  {cj.  v)). 

Dorsal  abscess  and  lumbar  abscess  are  treated  after  the 
same  plan  as  psoas  abscess,  although  one  incision  only  is 
usually  necessary  unless  the  fluid  has  travelled  to  a  distant 
point. 

A  postpharyngeal  abscess  must  not  be  opened  through 
the  mouth.  To  open  it  in  this  manner  puts  the  patient  in 
danger  of  suffocation  by  fluid  running  into  the  larynx  during 
or  after  the  operation.  Further  mixed  infection  of  the 
abscess-area  will  be  certain  to  ensue.  Septic  pneumonia 
will  be  apt  to  arise  from  inhaled  infected  particles,  and  pro- 
found gastro-intestinal  disturbance  will  be  liable  to  develop 
because  of  the  inevitable  swallowing  of  purulent,  putrid,  and 
tubercular  masses.  Incise  the  neck  and  open  by  Hilton's 
method,  going  through  the  sternocleidomastoid  muscle  or 
behind  it.  Rub  the  wall  with  bits  of  gauze,  remove  any  loose 
bone,  irrigate  with  hot  normal  salt  solution,  inject  iodoform 
emulsion,  insert  a  tube  or  pack  with  iodoform  gauze. 

VII.    ULCERATION    AND    FISTULA. 

An  ulcer  is  a  loss  of  substance  due  to  necrosis  of  a 
superficial  structure.  The  action  of  the  pus  organisms  is 
the  same  as  in  an  abscess.  A  broken  abscess  becomes  an 
ulcer,  and  an  ulcer  is  a  half-section  of  an  abscess.  The 
floor  of  an  ulcer  consists  of  granulation-tissue  and  corre- 
sponds with  the  abscess-wall.  An  abscess  arises  from 
molecular  death  within  the  tissues ;   an   ulcer,  from  molec- 


ULCERATION  AND  FISl^ULA.  Ill 

ular  death  of  a  free  surface.  An  ulcer  must  not  be  con- 
founded with  an  excoriation.  In  an  ulcer  the  corium  is 
always,  and  the  subcutaneous  tissue  is  generally,  destroyed, 
and  a  scar  is  left  after  healing.  In  an  excoriation  the  mucous 
layer  of  epithelium  is  exposed,  or  this  is  destroyed  and  the 
corium  exposed.  In  an  excoriation  the  corium  is  never 
destroyed,  and  no  scar  remains  after  healing.  An  ulcer 
heals  by  granulation  (p.  84).  Embryonic  tissue  by  vascu- 
larization becomes  granulation-tissue,  granulation-tissue  is 
converted  into  fibrous  tissue,  the  fibrous  tissue  contracts, 
and  by  pulling  the  edges  of  the  ulcer  toward  each  other 
lessens  the  size  of  the  cavity.  When  the  granulations  reach 
the  level  of  the  skin  the  epithelium  at  the  edges  of  the  ulcer 
proliferates  and  the  sore  is  soon  covered  over  with  new 
epithelium. 

Necrosis  may  arise  from — (i)  Inflammation.  The  press- 
ure of  the  exudate  can  cut  off  the  circulation,  or  bacteria 
may  directly  destroy  tissue.  Suppuration  occurs.  (2)  The 
action  of  pus  bacteria,  causing  primary  cell-necrosis.  (3) 
Bacteria  of  putrefaction  and  organisms  of  suppuration  acting 
upon  a  wound.  (4)  Traumatism  or  irritants,  producing  at 
once  stasis,  which  is  added  to  by  secondary  inflammation, 
the  exudate  undergoing  purulent  liquefaction.  (5)  Pro- 
longed pressure.  (6)  Deficient  blood-supply.  (7)  Faulty 
venous  return.  (8)  Degeneration  of  a  neoplastic  infiltration 
(gummatous,  malignant,  or  tubercular).  (9)  Trophic  dis- 
turbance. (10)  Nutritional  disturbances  (as  scurvy).  Most 
ulcers  are  due  to  pus  organisms,  and  even  those  that  arise 
from  something  else  (as  gummatous  degeneration)  are  apt 
to  suppurate. 

Classification. — Ulcers  are  classified  into  groups  ac- 
cording to  the  condition  of  the  ulcer  and  the  associated 
constitutional  state.  In  the  first  group  we  find  the  varicose, 
hemorrhagic,  acute,  chronic,  irritable,  neuralgic,  etc.  In  the 
second  group  are  placed  the  tubercular,  syphilitic,  senile, 
scorbutic,  etc.  All  ulcers,  whatever  their  origin,  are  either 
aaitc  or  cJiroiiic,  and  such  conditions  as  great  pain,  hemor- 
rhage, edema,  exuberant  granulations,  phagedena,  slough- 
ing, eczema,  gout,  syphilis,  scurvy,  etc.,  are  to  be  looked  upon 
as  complications.  The  leg  is  so  common  a  site  of  ulcers  as 
to  warrant  a  special  description  of  ulcers  of  this  part.  In 
describing  an  ulcer  state  the  patient's  previous  history ;  the 
supposed  cause ;  the  situation  ;  the  outline ;  the  duration ; 
and  the  mode  of  onset  of  the  ulcer.  State  if  the  ulcer  is 
single  or  if  multiple  sores  exist,  and  if  there  is  or  is  not  pain. 


112  MODERN  SURGERY. 

Whether  or  not  any  healing  has  ever  occurred,  and  the  pa- 
tient's constitutional  condition.  Set  forth  the  complications  ; 
the  state  of  anatomically  related  glands  ;  the  condition  of  the 
edge,  the  floor,  and  the  parts  about  the  ulcer,  and  the  nature 
and  quantity  of  the  discharge. 

Acute  ulcer  of  the  leg  may  follow  an  acute  inflamma- 
tion and  may  be  acute  from  the  start,  or  may  be  first  chronic 
and  then  become  acute.  It  is  characterized  by  rapid  progress 
and  intense  inflammation.  There  is  rarely  more  than  one 
ulcer.  In  outline  these  ulcers  are  usually  oval,  but  may  be 
irregular.  The  floor  of  an  acute  ulcer  is  covered  with  a 
mass  of  gray  aplastic  lymph,  or  it  may  have  upon  it  large 
greenish  sloughs.  The  edges  are  thin  and  undermined. 
The  discharge  is  very  profuse  and  ichorous,  excoriating  the 
surrounding  parts.  The  adjacent  surface  is  inflamed  and 
edematous.  There  is  much  burning  pain.  In  some  cases 
the  glands  in  the  groin  enlarge.  When  the  ulcer  spreads 
with  great  rapidity  and  becomes  deeper  as  well  as  larger  in 
surface-area,  it  is  called  "  phagedenic."  If  sloughs  form, 
this  indicates  that  tissue-death  is  going  on  so  rapidly  that 
the  dead  portions  have  not  time  to  break  down  and  be  cast 
off  Limited  stasis  produces  molecular  death  ;  more  exten- 
sive stasis,  a  slough.  Constitutionally,  there  is  gastro-intes- 
tinal  derangement,  but  rarely  fever. 

Treatment. — In  treating  an  acute  ulcer  of  the  leg,  give  a 
dose  of  blue  mass  or  calomel,  followed  in  eight  or  ten  hours 
by  a  saline  (.^ij  each  of  Rochelle  and  Epsom  salt).  Order 
light  diet.  Deny  stimulants  except  in  diphtheritic  ulcer. 
Administer  opium  if  pain  is  severe.  Insist  upon  rest  in  the 
recumbent  position  with  the  leg  elevated.  Use  a  spray  of 
hydrogen  peroxid  and  the  scissors  and  forceps  to  get  rid  of 
sloughs,  and  after  sloughs  are  removed  wash  the  ulcer  with 
corrosive  sublimate  solution  (i  :  looo).  If  the  sloughs  can- 
not be  removed  completely,  use  an  antiseptic  poultice. 
After  asepticizing  local  bleeding  is  of  great  value.  Tie  a 
fillet  below  the  knee,  make  multiple  punctures  in  the  parts 
about  the  ulcer,  and  let  the  patient  sit  with  his  leg  in  tepid 
water  until  six  or  eight  ounces  of  blood  have  been  lost ; 
then  untie  the  fillet  and  dress  with  antiseptic  poultices,  keep- 
ing the  leg  elevated.  In  two  days  paint  around  the  ulcer 
with  equal  parts  of  tincture  of  iodin  and  alcohol,  and  repeat 
this  treatment  every  day,  dusting  the  ulcer  with  iodoform, 
covering  it  with  gauze,  and  producing  pressure  by  means  of 
a  roller. 

Many  cases  do  very  well  after  local  bleeding  and  antisep- 


ULCERATION  AND  FISTULA.  II3 

tization  by  the  local  use  of  lead-water  and  laudanum  upon 
the  inflamed  parts  around  the  ulcer,  a  roller  bandage  being 
applied  to  make  compression.  The  lead-water  and  laud- 
anum should  not  be  applied  to  the  ulcer,  but  around  about 
it.  The  ulcer  is  dressed  with  an  antiseptic  poultice.  If  the 
discharge  is  offensive,  dress  antiseptically,  apply  acetanilid, 
aristol,  or  iodoform,  or  use  gr.  iij  of  chloral  to  every  5j  of 
water.  A  25  per  cent,  ointment  of  ichthyol  is  very  useful 
applied  around  the  ulcer.  If  sloughs  continue  to  form, 
touch  with  a  I  :  8  solution  of  acid  nitrate  of  mercury  or  with 
a  solution  of  pure  carbolic  acid,  and  reapply  antiseptic  poul- 
tices. If  an  ulcer  continues  to  spread,  clean  it  up  with  per- 
oxid  of  hydrogen,  dry  with  absorbent  cotton,  touch  with 
nitrate-of-mercury  solution  (i  :  8),  and  apply  an  antiseptic 
poultice.  Repeat  the  application  of  nitrate  of  mercury  every 
day  until  the  ulcer  ceases  to  extend  and  granulations  begin 
to  form. 

In  an  ulcer  covered  with  a  great  mass  of  aplastic  lymph 
touch  daily  with  solution  of  silver  nitrate  (gr.  xl  to  §j)  or 
with  acid  nitrate  of  mercury  (1:15),  and  dress  with  iodo- 
form and  antiseptic  fomentations.  Give  internally  tonics, 
stimulants,  and  good  food.  In  any  case,  when  granulations 
form  we  should  dress  antiseptically  with  dry  dressings,  or 
we  can  employ  a  non-irritant  ointment,  such  as  cosmolin. 
If  granulation  is  slow,  touch  every  day  with  a  solution  of 
silver  nitrate  (gr.  x  to  §j)  and  dress  antiseptically,  or  with  a 
stimulating  ointment  (resin  cerate  or  3j  of  ung.  hydrarg. 
nitratis  to  3vij  of  ung.  petrolii),  or  with  an  ointment  of  copper 
sulphate,  gr.  iij  to  |j,  or  with  3  drops  of  nitric  acid  to  5j  of 
gum  Arabic. 

Chronic  ulcer  of  the  leg  is  characterized  by  low  action 
and  slow  progress.  It  may  be  chronic  from  the  start,  or  it 
may  result  from  acute  ulcer.  More  usually  it  is  found  as  a 
solitary  ulcer  two  inches  above  the  internal  malleolus.  Syph- 
ilitic ulcers  often  occur  in  a  group,  are  usually  crescentic, 
and  are  frequent  upon  the  front  of  the  knee.  A  tubercular 
ulcer  may  have  no  granulations,  but  is  usually  covered  with 
pale  edematous  granulations,  which  signify  the  existence  of 
a  tendency  to  venous  stasis.  The  edges  of  the  tubercular 
ulcer  are  undermined  and  irregular,  the  parts  about  it  are 
livid  and  tender,  and  the  discharge  is  thin  and  scanty  (p.  152). 
An  ordinary  chronic  ulcer  is  circular  or  oval,  and  is  sur- 
rounded by  congested,  discolored,  and  indurated  skin,  this 
induration  being  due  to  fibrous  tissue,  and  there  is  often  ec- 
zema or  a  brown  pigmentation  of  the  neighboring  skin.    The 


114  MODERN  SURGERY. 

floor  of  the  ulcer  is  uneven,  and  usually  is  covered  with 
granulations,  each  of  which  is  red  and  the  size  of  a  pin-point, 
but  which  may  be  exuberant  or  edematous.  If  granula- 
tions are  absent,  the  ulcer  has  the  appearance  of  a  piece  of 
liver,  or  is  smooth  and  glazed.  The  edges  are  thick,  turned 
out,  and  not  sensitive  to  the  touch.  Occasionally,  but 
rarely,  they  are  thin  and  undermined.  Some  ulcers  are 
indurated  and  adherent ;  this  adhesion  to  the  deeper  struc- 
tures prevents  healing  by  antagonizing  contraction.  An 
ulcer  may  fail  to  heal  because  of  severe  infection ;  because 
of  want  of  rest;  because  of  absence  of  granulations,  the 
result  of  deficient  blood-supply ;  because  of  edematous 
granulations  ;  because  of  exuberant  granulations ;  because 
of  adhesion  to  deep  structures,  and  because  of  some  con- 
stitutional disease. 

Treatment. — In  treating  a  chronic  ulcer,  give  a  saline 
every  day  or  so.  Treat  any  existing  diathesis.  Insist  on  rest 
and,  if  possible,  elevation.  Asepticize  the  ulcer.  Draw  blood 
by  shallow  scarifications  of  the  bottom  of  the  ulcer  and  the 

skin.  If  the  ulcer  is  adher- 
ent, make  incisions  like  either 
of  those  shown  in  Fig.  32, 
each  cut  going  through  the 
deep  fascia.  These  incisions, 
besides  permitting  contrac- 
tion,   allow    granulations    to 

Fig.  32.-Incisions  for  adherent  ulcer.  SprOUt    in    them,  which    CaUSC 

the  absorption  of  the  exudate. 
After  incision  keep  the  part  elevated  and  dressed  antiseptic- 
ally  for  two  days.  In  two  days  after  scarification  or  incision 
scrape  the  ulcer  with  a  curet  until  sound  tissue  is  reached. 
Use  antiseptic  poultices  for  two  days  more,  then  paint  around 
the  ulcer  with  tincture  of  iodin  and  alcohol  (1:3),  dress  the 
parts  about  the  ulcer  with  hot  lead-water  and  laudanum, 
and  dress  the  ulcer  antiseptically  or  with  sterile  gauze.  In 
a  day  or  so  the  lead-water  can  be  discontinued  and  the 
ulcer  can  be  dressed  antiseptically  with  sterile  gauze,  nor- 
mal salt  solution,  boric  acid,  bichlorid  of  palladium,  chlorin- 
water,  solution  of  permanganate  of  potassium,  sulphur, 
glutol,  protonuclein,  or  bovinin.  Glutol  (formalin-gela- 
tin) is  very  useful  in  some  cases  and  so  is  protonuclein. 
When  healing  begins,  treat  as  outlined  for  healing  acute 
ulcer  (p.  1 13). 

Complications. — Remove  by  scissors  and  forceps  any 
useless  tissue.    Take  out  dead  bone  ;  slit  sinuses  ;  trim  over- 


ULCERATION  AND   FISTULA.  II5 

hanging  edges.  Treat  eczema  by  attention  to  the  bowels  and 
stomach,  and  locally  by  washing  with  ethereal  soap  and  by 
the  use  of  powdered  oxid  of  zinc  or  borated  talcum,  the  leg 
being  wrapped  in  cotton.  Avoid  ordinary  soap,  grease,  and 
ointment.  Varicose  veins  demand  either  ligation  at  several 
points,  excision,  incision  by  Schede's  method  (p.  274),  or  the 
continued  use  of  a  flannel  roller  or  a  Martin  rubber-bandage. 
Never  operate  on  varicose  veins  if  any  phlebitis  exists.  In- 
flammation is  met  by  rest,  elevation,  painting  the  neighbor- 
ing parts  with  dilute  iodin,  and  applying  about  the  ulcer  a 
hot  solution  of  lead-water  and  laudanum.  For  calloused 
edges,  blister,  employ  radiating  incisions,  or  cut  the  edges 
away.  Ordinary  thick  edges  can  be  strapped.  In  strapping 
use  adhesive  plaster  and  do  not  completely  encircle  the  limb. 
For  edematous  granulations  apply  pressure  by  a  flannel 
bandage,  a  rubber  bandage,  or  adhesive  plaster  strapping. 
When  the  parts  are  adherent  the  ulcer  is  immovable,  being 
firmly  anchored  to  structures  beneath  it.  In  such  a  condi- 
tion completely  or  partly  surround  the  sore  with  a  cut  through 
"the  deep  fascia  (Fig.  32).  This  cut  sets  the  ulcer  free  from 
its  anchorage  and  permits  it  to  contract.  If  the  bottom  of  the 
ulcer  is  foul,  dry  it  and  touch  with  a  solution  of  acid  nitrate 
of  mercury  (i  :  8)  or  with  crystals  of  pure  carbolic  acid.  Re- 
peat this  every  third  day  and  dress  with  an  antiseptic  poultice 
until  granulations  appear.  Superfluous  granulations  (proud 
flesh)  should  be  cut  away  or  mowed  down  with  silver  nitrate. 
Absence  of  granulations  or  scantiness  of  granulations  means 
deficiency  of  blood-supply.  The  surgeon  endeavors  to  bring 
more  blood  to  the  part,  and  to  do  this  induces  inflammation. 
The  usual  method  of  procedure  is  to  apply  daily  to  the  sore 
a  solution  of  nitrate  of  silver  (10  to  15  grains  to  the  ounce). 
In  obstinate  cases  blister  the  ulcer  or  scrape  it,  or  paint  it 
with  tincture  of  iodin,  or  apply  pure  carbolic  acid,  or  touch 
with  the  actual  cautery. 

Irritable  ulcer  is  due  to  exposure  of  a  nerve  and  destruc- 
tion of  its  sheath.  Find  with  a  probe  the  painful  granulation 
and  divide  it  with  a  tenotome,  or  curet  the  ulcer  or  burn  it 
with  solid  stick  of  silver  nitrate.  If  healing  entirely  fails, 
skin-graft.  Among  the  methods  of  skin-grafting  are — (i) 
Reverdin's,  (2)  Thiersch's,  and  (3)  Krause's.  (See  Plastic 
Surgery}^ 

When  a  man  having  an  ulcer  must  go  out,  use  a  firmly 
applied  roller,  or,  better  still,  a  Martin  bandage.  This  band- 
age, which  is  made  of  red  rubber,  limits  the  amount  of  arte- 
rial blood  going  to  the  ulcer  and  favors  venous  flow  from  the 


Il6  MODERN  SURGERY. 

sore  and  its  neighborhood.  The  bandage  should  be  used  as 
follows  :  before  getting  out  of  bed  spray  the  sore  with  hydro- 
gen peroxid  by  means  of  an  atomizer,  dry  off  the  froth  with 
cotton,  wash  the  leg  with  soap  and  water,  dry  it,  and  put  on 
the  bandage — all  of  which  should  be  done  before  putting  a 
foot  to  the  floor.  At  night,  after  getting  in  bed,  take  off  the 
bandage,  wash  it  with  soap  and  water,  hang  it  over  a  chair 
to  dry,  and  again  cleanse  the  leg  and  ulcer.  If  these  rules 
are  not  strictly  observed,  the  Martin  bandage  will  produce 
pain,  suppuration,  and  eczema   of  the  leg. 

Tubercular  Ulcers  (p.  1 5  2). 

Syphilitic  Ulcers  (p.  197). 

A  healthy  ulcer  is  covered  with  small,  bright-red  granu- 
lations which  bleed  on  touching,  are  painless,  and  grow  rap- 
idly. The  edges  are  soft  and  show  the  opalescent  blue  Hne 
of  proliferating  epithelium.  The  sore  is  movable,  the  dis- 
charge is  purulent  and  yellow,  and  the  parts  about  are  not 
inflamed. 

Various  Ulcers. — The  fangous  or  exuberant  ulcer  is 
especially  common  in  burns  and  other  injuries  when  cicatri- 
cial contraction  causes  venous  obstruction.  The  granulations 
form  rapidly  and  mount  above  the  level  of  the  skin.  These 
granulations  bleed  when  touched.  Burn  them  off  with  solid 
stick  of  silver  nitrate,  or  cut  them  off  with  a  sharp  knife ;  stop 
hemorrhage  if  there  be  any,  and  strap  or  use  the  rubber 
bandage. 

A  varicose  ulcer  is  usually  single,  is  oval,  round,  or  ir- 
regular in  outHne,  and  is  most  often  seen  above  the  inner 
malleolus.  Its  edges  are  thick,  everted,  and  swollen.  This 
swelling  is  largely  due  to  edema,  and  is  found  to  pit  on 
pressure.  The  edges  are  not  undermined,  but  slope  gently 
to  the  floor  of  the  ulcer.  The  floor  is  usually  covered  with 
rather  large  granulations  which  bleed  freely  on  touching.  In 
a  varicose  ulcer  the  destruction  of  tissue  often  begins  at  the 
margin  of  a  congested  area  and  advances  toward  the  centre. 
Such  an  ulcer  is  usually  surrounded  by  eczema. 

Erethistic,  irritable,  or  painful  ulcers,  which  are  very 
sensitive,  are  due  to  the  exposure  of  nerve-filaments  and 
destruction  of  their  sheaths.  They  are  especially  found  near 
the  ankle,  over  the  tibia,  in  the  anus  (fissure),  or  in  the 
matrix  of  the  nail  (ingrowing  nail).  Curet  an  erethistic 
ulcer,  and  touch  with  pure  carbolic  acid  or  with  the  solid 
stick  of  silver  nitrate.  Chloral,  gr.  xx  to  the  ounce,  allays 
the  pain ;  so  do  cocain  and  eucain  for  a  time. 

The  indolent  ulcer  has   no  granulations   and   shows  no 


ULCERATION  AND  FISTULA.  WJ 

tendency  to  heal.  It  requires  stimulating  applications  to  in- 
crease the  blood-supply. 

The  hemorrhag-ic  ulcer  bleeds  easily  and  profusely.  Press- 
ure must  be  applied,  and  it  is  sometimes  necessary  to  cut 
away  or  burn  away  the  granulations. 

Phagedenic  Ulcer. — The  phagedenic  ulcer,  which  means 
the  profound  microbic  infection  of  tissues  debilitated  by 
local  or  constitutional  disease,  is  commonly  venereal.  This 
ulcer  has  no  granulations  and  is  covered  with  sloughs  ;  its 
edges  are  thin  and  undermined,  and  it  spreads  rapidly  in  all 
directions.  It  requires  the  use  of  strong  caustics  or  Paque- 
lin's  cautery  followed  by  iodoform  dressing  and  antiseptic 
poultices.     Internally,  use  tonics  and  stimulants. 

The  callous  ulcer  is  sunken  deeply  below  the  level  of  the 
skin.  Its  border  is  hard  and  knobby.  Its  floor  shows  no 
granulations,  and  is  either  smooth  and  glistening  or  foul  and 
liver-colored.  The  discharge  is  thin  and  scanty,  and  the  ulcer 
varies  little  in  appearance  from  week  to  week  or  even  from 
month  to  month.  The  treatment  is  scraping  and  cauteriza- 
tion of  the  ulcer ;  cutting  through  the  edges  by  radiating  in- 
cisions ;  application  of  antiseptic  dressings,  and  a  firm  band- 
age. In  some  cases  strap  the  ulcer.  In  severe  cases  cut  the 
ulcer  out  and  skin-graft. 

A  rodent  or  Jacob's  ulcer  is  a  superficial  epithelioma 
developing  from  sebaceous  glands,  sweat-glands,  or  hair- 
follicles.  It  requires  scraping  and  cauterization,  or,  what  is 
better,  excision. 

Decubital  ulcer,  or  bed-sore,  is  due  to  pressure  upon  an 
area  of  feeble  circulation  (p.  130). 

Neuroparalytic  or  trophic  ulcer  is  due  to  impairment  of 
the  trophic  centres  in  the  cord. 

The  perforating  ulcer,  a  name  given  by  Vesigne,  com- 
monly affects  the  metatarsophalangeal  joint  or  the  pulp  of 
the  great  toe  about  a  corn.  The  parts  about  the  corn  in- 
flame, and  pus  forms  and  reaches  into  the  bone.  A  sinus 
evacuates  the  pus  by  the  side  of  the  corn.  As  this  ulcer 
may  be  present  in  anesthetic  leprosy,  paralyzed  limbs,  and 
tabes  dorsalis,  and  as  the  part  on  which  it  occurs  is  apt  to 
be  sweaty,  cold,  and  more  or  less  anesthetic,  and  as  the  sore 
may  be  hereditary,  it  is  usually  set  down  as  trophic  in  origin. 
Treatment  of  a  perforating  ulcer  consists,  according  to  Treves, 
in  going  to  bed  and  poulticing.  Every  time  a  poultice  is  re- 
moved the  raised  epithelium  around  the  ulcer  is  cut  away  and 
then  the  poultice  is  reapplied.  In  about  two  weeks  an  ulcer 
remains  surrounded  by  healthy  tissue.      Treves  treats  this 


Il8  MODERN  SURGERY. 

sore  with  glycerin  made  to  a  creamy  consistency  with  sali- 
cylic acid,  to  each  ounce  of  which  TTLx  of  carbolic  acid  have 
been  added.  He  directs  the  patient  to  wear  during  the  rest 
of  his  life  some  form  of  bunion-plaster  to  keep  off  pressure. 
If  in  a  perforating  ulcer  the  bone  is  diseased,  it  must  be  re- 
moved. This  ulcer  tends  to  recur  in  the  same  spot  or  in 
adjacent  parts,  and  it  may  be  necessary  to  amputate  the  toe 
or  the  foot. 

The  scorbutic  ulcer  is  covered  with  a  dark-brown  crust, 
beneath  which  are  pale  and  bleeding  granulations.  The  parts 
adjacent  are  of  a  violet  color. 

Epitheliomatous,  sarcomatous,  tubercular,  and  syphilitic 
ulcers  are  considered  under  these  respective  diseases. 

Fistula. — A  fistula  is  an  abnormal  communication  be- 
tween the  surface  and  an  internal  part  of  the  body,  or 
between  two  natural  cavities  or  canals.  The  first  form  is 
seen  in  a  rectal  fistula,  a  urethral  fistula,  or  a  biliary  fistula, 
and  the  second  form  is  seen  in  a  vesicovaginal  fistula.  Fis- 
tulae  may  result  from  congenital  defect,  as  when  there  is  fail- 
ure in  the  closure  of  the  branchial  clefts,  and  can  arise  from 
sloughing,  traumatism,  and  suppuration.  Fistulae  are  named 
from  their  situation  and  communications. 

A  sinus  is  a  tortuous  track  opening  usually  upon  a  free 
surface  and  leading  down  into  the  cavity  of  an  imperfectly- 
healed  abscess.  A  sinus  may  be  an  unhealed  portion  of  a 
wound.  Many  sinuses  may  be  due  to  pus  burrowing  subcu- 
taneously.  A  sinus  fails  to  heal  because  of  the  presence  of 
some  irritant  fluid  (as  saliva,  urine,  or  bile) ;  because  of  the 
existence  of  a  foreign  body,  as  dead  bone,  a  bit  of  wood,  a 
bullet,  a  septic  ligature,  etc. ;  or  because  of  rigidity  of  the 
sinus-walls,  which  rigidity  will  not  permit  collapse.  The 
walls  of  a  tubercular  sinus  are  lined  with  a  material  identical 
with  the  pyogenic  membrane  of  a  cold  abscess.  Sinuses 
may  be  maintained  by  want  of  rest  (muscular  movements) 
and  general  ill-health. 

Treatment. — In  treating  a  fistula,  remove  any  foreign 
body,  lay  the  channel  open,  curet,  swab  with  pure  car- 
bolic acid,  and  pack  with  iodoform  gauze.  In  obstinate 
cases  entirely  extirpate  the  fibrous  walls,  sew  the  deeper 
parts  of  the  wound  with  buried  catgut  sutures  and  approxi- 
mate the  skin-surfaces  with  interrupted  sutures  of  silkworm 
gut.  Fresh  air  is  a  necessity,  and  nutritious  food  and  tonics 
must  be  ordered. 


MORTIFICATION,    GANGRENE,    OR   SPHACELUS.        II9 

VIII.  MORTIFICATION,  GANGRENE,  OR    SPHACELUS. 

Mortification  or  gangrene  is  death  in  mass  of  a  portion 
of  the  surface  of  the  living  body — the  dead  portions  being 
visible — in  contrast  to  ulceration  or  molecular  death,  in 
which  the  dead  particles  are  too  small  to  be  seen  and  are 
cast  away.  Gangrene  is  in  reality  a  form  of  necrosis.  But 
clinically  the  term  necrosis  is  restricted  to  molar  death  of 
bone  or  to  death  of  parts  below  the  surface.  In  gangrene 
the  dead  portions  may  either  desiccate  or  putrefy.  Gan- 
grene may  be  due  to  tissue-injury,  either  chemical  or  me- 
chanical, to  heat  or  cold,  to  failure  of  the  general  health,  to 
circulatory  obstruction,  to  nerve-disorder,  the  nerves  in- 
volved being  the  vasomotor  or  possibly  the  trophic,  or  to 
microbic  infection.  A  microbic  poison  can  directly  destroy 
tissues.  It  can  indirectly  destroy  them  by  causing  such 
inflammation  that  the  products  obstruct  the  circulation. 
When  the  mortified  portion  is  entirely  dead  the  process 
is  spoken  of  as  "  sphacelus." 

Classification. — Gangrene  is  divided  into  the  following 
three  great  groups : 

(i)  Dry  gangrene,  which  is  due  to  circulatory  interference, 
the  arterial  supply  being  decreased  or  cut  off.  As  venous 
return  is  still  active,  all  fluid  is  taken  up  from  the  tissues, 
which  shrivel  and  mummify. 

(2)  Moist  gangrene,  which  is  due  to  interference  not  only 
with  arterial  ingress,  but  also  with  venous  return  or  capillary 
circulation,  the  dead  parts  remaining  moist. 

(3)  Septic  gangrene,  arising  from  virulent  septic  matter 
coming  from  outside.  In  this  form  the  septic  process  causes 
the  gangrene,  and  is  not  merely  associated  with  it. 

There  are  many  gangrenous  processes  which  belong  under 
one  or  other  of  the  above  heads,  namely :  co7igenital  gan- 
grene, a  rare  form  existing  at  birth  ;  constitutional  gangrene, 
arising  from  a  constitutional  cause,  as  diabetes ;  ciitajieoiis 
gangrene,  which  is  limited  to  skin  and  subcutaneous  tissue, 
as  in  phlegmonous  erysipelas ;  gaseous  or  cuiphyseviatous 
gangrene,  in  which  the  subcutaneous  tissues  are  filled  with 
putrefactive  gases  and  crackle  on  pressure ;  diabetic  or  gly- 
cemic,  due  to  diabetes  ;  hospital  gangrene,  which  is  defined 
by  Foster  as  specific  serpiginous  necrosis,  the  tissues  being 
pulpefied :  some  consider  it  a  traumatic  diphtheria ;  cold 
gangrene,  a  form  in  which  the  parts  are  entirely  dead 
(sphacelus) ;  hot  gangrene,  which  presents  some  inflamma- 
tion, as  shown  by  heat ;  dermatitis  gaugrcenosa  infantum,  or 


I20  MODERN  SURGERY. 

the  multiple  cachectic  gangrene  of  Simon ;  idiopathic  gan- 
grene, which  has  no  ascertainable  cause ;  mixed,  which  is 
partly  dry  and  partly  moist ;  primary,  in  which  the  death  of 
the  part  is  direct,  as  from  a  burn ;  secondary,  which  follows 
an  acute  inflammation  ;  multiple,  as  gangrenous  herpes  zoster ; 
diabetic  gangrene,  which  arises  during  the  existence  of  dia- 
betes ;  gangrenous  ecthyma,  a  gangrenous  condition  of  ec- 
thyma ulcers ;  pressure,  which  is  due  to  long  compression ; 
purpuric  or  scorbutic,  which  is  due  to  scurvy ;  Raynaud's  or 
idiopathic  symmetrical,  which  is  due  to  vascular  spasm  from 
nerve-disorder;  senile,  the  dry  gangrene  of  the  aged;  venous 
or  static,  which  is  due  to  obstruction  of  circulation,  as  in  a 
strangulated  hernia  ;  trophic,  which  is  due  to  nutritive  failure 
by  reason  of  disorder  of  the  trophic  nerves  or  centers  ; 
thrombotic,  which  is  due  to  thrombus ;  embolic,  which  is  due 
to  embolus ;  and  decubital  gangrene,  or  bed-sores  due  to 
pressure. 

Dry  or  chronic  gangrene,  Pott's  gangrene  (Fig.  33),  arises 


Fig.  33. — Chronic  gangrene  of  the  feet  (Gross). 

from  deficiency  of  arterial  blood.  Even  in  a  person  with 
healthy  arteries  dry  gangrene  may  result  from  injury  of  the 
main  trunk  of  an  artery  (lodging  of  an  embolus,  ligation,  or 
laceration).  Gangrene  only  follows  injury  when  the  anas- 
tomotic circulation  fails  to  sustain  the  part.  Obstruction 
due  to  thrombus  is  not  unusual  in  the  diseased  arteries  of 
the  aged.  When  an  embolus  lodges  in  an  artery  and  causes 
gangrene,  the  case  runs  the  following  course:  sudden  severe 
pain  at  the  seat  of  impaction,  and  also  tenderness ;  pulsation 
above,  but  not  below,  this  point ;  the  limb  below  the  obstruc- 
tion is  blanched,  cold,  and  anesthetic ;  within  forty-eight 
hours,  as  a  rule,  the  area  of  gangrene  is  widespread  and 
clearly  evident;  the  limb  becomes  reddish,  greenish,  blue. 


MORTIFICATION,    GANGRENE,    OR   SPHACELUS.        121 

and  then  black ;  the  skin  itself  becomes  shrivelled  and  its 
outer  layer  stony  or  like  horn  because  of  evaporation.  The 
entire  part  may  become  as  dry  as  a  mummy,  but  usually 
there  are  spots  where  some  fluid  remains,  and  these  spots 
are  soft  and  moist,  and  the  dead  tissue  where  it  joins  the 
living  is  sure  to  be  moist.  The  moist  areas  become  foul 
and  putrid,  but  the  dry  spots  do  not.  At  the  point  of  con- 
tact of  the  dead  and  living  tissue  inflammation  arises  in  the 
latter  structure,  a  bright-red  line  forms,  and  exudation  and 
ulceration  take  place.  This  line  of  ulceration  in  the  sound 
tissues  is  called  the  "  line  of  demarcation."  It  is  Nature's 
effort  at  amputation,  and  in  time  may  get  rid  of  a  large  por- 
tion of  a  limb,  and  then  heal  as  any  other  ulcer.  In  dry  gan- 
grene from  arterial  obstruction  there  are  gastro-intestinal  de- 
rangement and  some  fever.  The  gangrene  does  not  extend 
up  to  the  point  of  obstruction,  but  only  to  a  region  in  which 
the  anastomotic  circulation  is  sufficiently  active  to  permit  of 
the  formation  of  a  line  of  demarcation.  Below  this  point  in- 
flammatory stasis  arises,  but  before  this  can  go  on  to  ulcera- 
tion the  parts  die.  In  cases  where  the  arterial  obstruction  is 
sudden  and  complete  the  limb  may  swell  considerably.  This 
is  due  to  the  sudden  loss  of  vis  a  tcrgo  in  the  arterial  system, 
venous  reflux  occurring  and  fluids  transuding.  In  such  a 
case,  though  the  tissues  contain  some  fluid  and  putrefy,  the 
process  is  pathologically  dry  gangrene.  Dry  gangrene  at- 
tacks the  leg  more  often  than  the  arm.  Thrombus  in  an 
artery  rarely  causes  gangrene  except  in  the  aged,  as  the 
circulation  has  time  to  adjust  itself;  but  gangrene  may  fol- 
low thrombus,  and  when  it  does  it  comes  on  more  slowly 
than  does  gangrene  from  embolus. 

Senile  gangrene  is  a  form  of  dry  gangrene  due  to  feeble 
action  of  the  heart  plus  obliterating  endarteritis  or  atheroma 
of  peripheral  vessels.  The  vessels  do  not  properly  carry 
blood,  and  may  at  any  time  be  occluded  by  thrombosis. 
In  a  drunkard,  or  in  a  victim  of  syphilis  or  tubercle,  the 
changes  supposed  to  characterize  old  age  may  appear  while 
a  man  is  young  in  years.  It  was  long  ago  said,  with  truth, 
"  a  man  is  as  old  as  his  arteries."  Senile  gangrene  most 
often  occurs  in  the  toe  or  the  foot. 

Symptoms. — A  man  whose  vessels  are  in  the  state  above 
indicated  is  generally  in  feeble  health  and  has  a  fatty  heart 
and  an  arcus  senilis  (a  red  or  white  line  of  fatty  degeneration 
around  the  cornea).  His  feet  feel  cold  and  numb,  and  they 
"  go  to  sleep "  very  easily.  He  is  dyspeptic  and  short  of 
breath,  and  his   urine  is  frequently  albuminous.     The  arte- 


122  MODERN  SURGERY. 

ries  are  felt  as  rigid  tubes,  like  pipe-stems.  He  is  in  much 
danger  of  edema  of  the  lungs  and  of  dry  gangrene.  A  very- 
slight  injury  of  a  toe  will  produce  extensive  inflammatory 
stasis,  which  completely  cuts  off  the  blood-supply  and 
causes  gangrene  of  the  part.  Gangrene  is  usually  an- 
nounced by  a  blue  spot,  followed  by  a  vesicle  which  lets 
out  bloody  serum  and  has  a  dry  floor.  The  tissues  adja- 
cent to  the  dead  toe  become  victims  to  stasis  and  gangrene, 
and  the  process  ascends  until  it  reaches  tissue  whose  circu- 
lation is  sufficiently  good  to  permit  of  ulceration  instead  of 
gangrene,  when  a  line  of  demarcation  forms.  The  dry  parts 
do  not  putrefy.  They  are  anesthetic,  hard,  leathery,  and 
wrinkled,  and  resemble  a  varnished  anatomical  specimen  or 
the  extremity  of  a  mummy  (hence  the  term  mummification). 
Before  the  line  of  demarcation  forms  there  is  some  burning 
pain ;  after  it  forms  pain  is  rarely  present.  If  embolism  or 
thrombus  in  a  diseased  vessel  caused  the  gangrene,  the  pain 
is  severe.  In  senile  gangrene  the  periphery  is  always  dry, 
the  part  nearer  the  body  being  generally  somewhat  moist. 
A  line  of  demarcation  may  start,  but  prove  abortive,  the  tis- 
sue mortifying  above  it.  This  proves  that  tissue  near  the  line 
is  in  a  state  of  low  vitality.  An  entire  leg  may  become  gan- 
grenous. When  a  limited  area  is  gangrenous  constitutional 
symptoms  are  trivial  or  are  absent,  but  when  a  large  area  is. 
involved  we  find  the  fever  of  septic  absorption.  Death  may 
ensue  from  exhaustion  caused  by  sleeplessness  and  pain,  from 
septic  absorption,  or  from  embolism  of  internal  organs.  In 
many  cases  of  senile  gangrene  thrombosis  arises  in  the  super- 
ficial femoral  artery  or  its  branches  (Heidenhain),  an  observa- 
tion it  is  important  to  bear  in  mind  when  amputating. 

Treatment  of  Dry  Gangrene. — When  injury  of  a  healthy 
artery  causes  us  to  fear  dry  gangrene  the  patient  should  be 
placed  in  bed  and  the  part  elevated  a  little,  kept  wrapped  up 
in  cotton-wool  and  warmed  with  hot  bottles  or  water-bags. 
The  dying  part  is  dressed  antiseptically,  and  the  surgeon  sees 
to  it  that  the  patient  gets  plenty  of  sleep  and  nourishment. 
It  is  advisable  to  give  tonics  and  stimulants.  Wait  for  a  line 
of  demarcation  and  amputate  well  above  it.  When  on  am- 
putating no  arterial  blood  flows,  perform  catheterism  of  the 
artery  with  a  filiform  bougie  or  a  fine  rubber  catheter.  In- 
sert the  instrument  into  the  artery,  and  work  it  up  and 
down  to  break  up  the  clot.  Bleeding  will  occur;  wash 
out  the  clot  and  then  tie  the  vessel.^  If  a  person  is  of  the 
type  in  which  there  is  danger  of  senile  gangrene,  he  should 

1  See  Mancozet's  report  before  second  Pan-American  Med.  Congress. 


MORTIFICATION,    GANGRENE,    OR  SPHACELUS.        1 23 

be  cautioned  against  injuring  his  feet,  especially  cutting  his 
corns  carelessly,  which  is  highly  dangerous ;  any  wound, 
however  slight,  requires  rest  and  antiseptic  dressing.  He 
must  wear  woollen  stockings,  put  a  hot-water  bag  to  his 
feet  on  cold  nights,  and  attend  to  his  general  health.  A 
little  whiskey  after  each  meal  is  indicated,  and  occasional 
courses  of  nitroglycerin  are  desirable. 

When  gangrene  occurs,  if  it  is  limited  to  one  toe  or  a  por- 
tion of  several  toes,  if  it  is  a  first  attack,  if  there  is  no  fever 
or  exhausting  diarrhea,  if  there  is  no  tendency  to  pulmonary 
congestion,  if  appetite  is  fair  and  sleep  refreshing,  we  can  await 
the  formation  of  a  line  of  demarcation.  While  awaiting  the 
line  of  demarcation  dress  the  part  antiseptically  and  raise  it 
about  two  inches  from  the  bed,  apply  warmth,  give  the  patient 
nourishing  diet,  stimulants,  and  tonics  ;  see  to  it  that  he  sleeps, 
and  watch  for  fever,  diarrhea,  pulmonary  congestion,  and 
kidney-failure.  When  a  line  forms,  dress  with  antiseptic  fo- 
mentations and  iodoform,  and  every  day  pick  away  dead  bits 
with  the  scissors  and  forceps.  In  many  cases  healing  will 
occur ;  but  even  when  the  parts  heal  the  patient  will  always 
be  in  deadly  peril  of  another  attack.  If  the  gangrene  shows 
a  tendency  to  spread,  if  it  involves  more  than  a  portion  of 
several  toes,  if  it  is  not  a  first  attack,  if  there  is  sleeplessness, 
fever,  exhausting  diarrhea,  absent  appetite,  or  a  strong  ten- 
dency to  pulmonary  congestion,  do  not  delay,  but  at  once  am- 
putate high  up.  If  the  gangrene  shows  no  tendency  to  limit 
itself,  or  if  the  patient  develops  sepsis  or  exhaustion,  at  once 
amputate  high  up.  The  best  point  at  which  to  amputate  is 
above  the  knee,  so  that  the  deep  femoral  artery,  which  rarely 
becomes  atheromatous,  will  nourish  the  flap.  Never  amputate 
below  the  tubercle  of  the  tibia.  Some  operators  disarticulate 
at  the  knee-joint.  Heidenhain  affirms  that  so  long  as  the 
gangrene  is  limited  to  one  or  two  toes  we  should  merely 
treat  it  antiseptically,  elevate  the  limb,  and  wait  for  the  dead 
part  to  be  cast  off  spontaneously ;  if,  however,  it  extends  to 
the  dorsum  or  sole  of  the  foot,  amputate  at  once  above  the 
knee.  He  further  states  that  gangrene  of  the  flaps  almost 
always  occurs  in  amputation  below  the  knee,  and  high  am- 
putation is  indicated  in  advancing  gangrene  with  or  without 
fever.^  When  amputation  has  been  performed  and  no  arte- 
rial bleeding  occurs,  clots  exist  in  the  femoral  artery.  If 
such  a  condition  exist,  insert  into  the  artery  a  fine  rubber 
sound  and  break  up  the  clot.  When  blood  runs  the  clot  is 
washed  out  (Severeanu). 

'  Deutsche  medicinische  Wochenschrift,  1891,  p.  1087. 


124  MODERN  SURGERY. 

In  moist  or  acute  gangrene  (Fig.  34)  the  dead  part  re- 
mains moist  and  putrefies.  It  results  from  interference  with 
venous  return  or  capillary  flow,  as  well  as  from  arterial  in- 
gress. It  may  arise  in  a  limb  after  ligation  or  destruction  of 
its  main  artery  and  vein,  after  long  constriction,  after  crushes 
and  lacerated  wounds,  and  after  thrombosis  of  the  vein. 
Moist  gangrene  may  follow  acute  inflammation,  or  may  be 


Fig.  34. — Acute  mortification  (Gross). 

due  to  local  constriction  (strangulated  hernia),  crushing, 
chemical  irritants,  heat,  and  cold. 

Moist  gangrene  of  a  limb  is  seen  typically  when  both 
vein  and  artery  are  damaged  or  destroyed.  The  leg  swells 
and  is  pulseless  below  the  obstruction ;  the  skin  becomes  cold, 
livid,  and  anesthetic,  and  is  raised  up  into  blebs  which  contain 
serosanguineous  fluid.  The  extremity  swells  enormously, 
there  is  pain  at  the  seat  of  obstruction,  and  sapremic  symp- 
toms quickly  develop.  The  bullae  break  and  disclose  the 
deeper  structures,  which  are  swollen  and  edematous.  The 
fetor  is  horrible.  Portions  of  the  extremity  become  em- 
physematous and  crepitate  on  pressure.  A  line  of  demarca- 
tion soon  forms. 

Moist  gangrene  from  inflammation  is  due  to  pressure  of 
the  exudate  cutting  off  the  blood-supply,  or  to  loss  of  blood- 
circulation  because  of  microbic  involvement  of  vessels  and 
clotting  of  blood.  It  occurs  in  phlegmonous  erysipelas. 
When  an  inflammation  is  about  to  terminate  in  gangrene  all 
the  signs  of  inflammation,  local  and  constitutional,  increase ; 
when  gangrene  occurs  they  cease,  bullae  and  emphysema  are 
noted,  with  great  swelling  and  all  the  other  symptoms  of 
molar  death.  The  sudden  cessation  of  pain  is  very  suggestive 
of  gangrene.  The  constitutional  symptoms  are  those  of  sup- 
purative fever  and  sapremia,  or  possibly  of  septic  infection. 

Treatment  of  Moist  Gangrene. — In  extensive  moist  gan- 
grene of  a  limb  wait  for  a  line  of  demarcation,  and  amputate 
clear  of  and  above  it.  While  waiting  for  the  line  to  form 
dress  the  dead  parts  antiseptically,  wrap  in  cotton,  apply 
heat,  and  slightly  elevate  the  limb.    Give  opium,  tonics,  nour- 


MORTIFICATION,    GANGRENE,    OR   SPHACELUS.        1 25 

ishing  food,  and  stimulants.  In  inflammatory  gangrene  re- 
lieve tension  by  incisions  and  then  cut  away  the  dead  parts, 
brush  the  raw  surface  with  pure  carbolic  acid,  dust  with 
iodoform,  and  dress  with  hot  antiseptic  fomentations.  Stim- 
ulate freely  and  feed  well. 

Gangrene  due  to  infective  organisms  comprises — (i) 
traumatic  spreading  gangrene ;  (2)  hospital  gangrene ;  (3) 
phagedena;   (4)  noma  vulvae;   and  (5)  cancrum  oris. 

Fulminating-  gangrene,  gangrenous  emphysema,  gan- 
grene foudroyante,  or  traumatic  spreading  gangrene,  re- 
sults from  a  virulent  infection  of  a  severe  wound  by  strepto- 
cocci and  organisms  of  putrefaction.  The  injury  damages 
the  main  vessels  of  the  limb,  the  pulse  below  the  injury  is 
imperceptible,  and  the  surgeon  is  often  at  this  time  uncertain 
whether  to  amputate  at  once  or  wait.  This  form  of  gangrene 
is  commonest  after  compound  fractures,  and  begins  within 
forty-eight  hours  after  the  accident.  It  does  not  begin  at 
the  periphery,  as  does  ordinary  moist  gangrene,  but  at  the 
wound-edges,  which  turn  red,  green,  and  finally  black ;  the 
extremity  soon  undergoes  a  like  change  and  becomes  morti- 
fied. The  entire  limb  swells  because  of  edema,  the  skin  peels 
off,  emphysema  sets  in,  and  the  extremity  becomes  anesthetic 
and  pulpy.  The  gangrene  spreads  up  and  down  from  the 
wound,  and  red  lines  run  from  above  the  wound.  These 
are  due  to  lymphangitis,  the  adjacent  lymph-glands  swell, 
and  in  thirty-six  hours  the  gangrene  may  involve  an  entire 
limb.  No  line  of  demarcation  forms.  The  system  is  soon 
overwhelmed  with  ptomains,  and  the  patient  has  septic  in- 
toxication, or  he  passes  into  profound  collapse  with  subnor- 
mal temperature.  Traumatic  spreading  gangrene  must  not 
be  confused  with  erysipelas.  In  erysipelas  the  color  is  red, 
pressure  instantly  drives  it  out,  and  on  the  release  of  pressure 
it  at  once  returns.  In  early  gangrene  the  color  is  purple, 
pressure  fails  to  drive  it  out  at  all  or  only  does  so  very  slowly, 
and  if  the  surface  is  blanched  by  pressure,  on  the  release  of 
pressure  the  color  crawls  slowly  back. 

Treatment. — In  treating  traumatic  spreading  gangrene  a 
line  of  demarcation  need  not  be  waited  for,  as  none  can  form. 
Amputation  should  at  once  be  performed  high  up,  the  flaps 
are  brushed  with  pure  carbolic  acid,  and  stimulants  must  be 
given  in  large  amount. 

Hospital  gangrene  or  sloughing  phagedena  is  a  disease 
that  has  practically  disappeared  from  civilized  communities. 
It  formerly  occurred  in  crowded,  ill-ventilated  hospitals.  Some 
consider  it  traumatic  diphtheria.     Koch  thinks  it  is  due  to 


126  MODERN  SURGERY. 

streptococci.  Jonathan  Hutchinson  says,  "  hospital  gangrene 
is  set  up  by  admitting  to  the  wards  a  case  of  syphilitic  phage- 
dena." It  may  show  itself  as  a  diphtheritic  condition  of 
a  wound,  as  a  process  in  which  sloughs  Hke  masses  of 
tow  form,  or  as  a  phagedenic  ulceration.  The  surrounding 
parts  are  inflamed  and  painful,  and  buboes  form  in  adjacent 
lymphatic  glands.  The  system  passes  into  a  low  septic 
state. 

Treatment. — In  treating  hospital  gangrene  ether  should  be 
given,  the  large  sloughs  removed  with  scissors  and  forceps, 
the  part  dried  with  cotton  and  cauterized  with  bromin.  Take 
a  tumblerful  of  water  and  into  it  pour  the  bromin :  this  falls 
to  the  bottom ;  draw  it  up  with  a  syringe  and  inject  it  into 
the  depths  of  the  wound.  The  wound  is  plentifully  sprinkled 
with  iodoform  and  is  dressed  with  antiseptic  poultices  until 
the  sloughs  separate,  when  the  sore  is  treated  as  an  ordinary 
ulcer.  Constitutional  treatment  is  that  of  sepsis.  If  a  limb  is 
hopelessly  damaged  by  this  form  of  gangrene,  we  must  wait 
for  a  line  of  demarcation  and  amputate. 

Special  Forms  of  Gangrene. — Symmetrical  or  Ray- 
naud's gangrene  arises  in  severe  cases  of  Raynaud's  disease. 
It  is  a  dry  gangrene.  Raynaud's  disease,  a  vasomotor  neu- 
rosis seen  in  children  and  young  adults,  is  characterized  by 
attacks  of  cold,  dead  bloodlessness  in  the  fingers  or  toes  as  a 
result  of  exposure  to  cold  or  of  emotional  excitement  (local 
syncope).  In  the  more  severe  cases  we  may  have  capillary 
congestion  and  livid  swelling  (local  asphyxia).  Chilblains 
belong  to  this  group.  The  patient  complains  of  pain,  ting- 
ling, and  stiffness.  It  is  after  local  asphyxia  that  the  gan- 
grene may  appear. 

This  gangrene  is  usually  seen  upon  the  ends  of  the  fingers 
or  the  toes,  but  it  may  attack  the  lobes  of  the  ears,  the  tip  of 
the  nose,  or  the  skin  of  the  arms  or  the  legs.  When  gan- 
grene is  about  to  occur  the  local  asphyxia  at  that  point 
deepens,  anesthesia  is  complete,  and  the  part  blackens  and 
becomes  cold.  The  epidermis  is  now  raised  up  into  blebs, 
which  rupture  and  expose  dry  surfaces.  A  line  of  demarca- 
tions forms,  and  the  necrosed  area  is  removed  as  a  slough. 
Widespread  gangrene  from  Raynaud's  disease  is  rare ;  there 
is  not  often  a  large  area  involved — rather  a  small  superficial 
portion.  Sometimes  the  disease  is  seen  upon  the  trunk. 
These  attacks  recur  again  and  again,  are  often  accompanied 
by  hemoglobinuria  (Osier),  and  are  sometimes  excited  by 
cold  or  by  mental  disturbance.  The  pathology  is  uncertain. 
Local  syncope  is  thought  to  be  due  to  vascular  spasm,  and 


MORTIFICATION,    GANGRENE,    OR   SPHACELUS.       12/ 

local  asphyxia  to  some  contraction  of  the  arterioles  with 
dilatation  of  the  capillaries  and  venules. 

TrcatDioit  of  Raynaud's  Disease. — When  attacks  of  Ray- 
naud's disease  arc  so  severe  as  to  threaten  gangrene,  the 
patient  should  be  put  to  bed ;  if  the  feet  are  affected,  elevate 
the  legs,  wrap  the  extremity  in  cotton-wool,  and  apply  heat. 
If  the  hands  are  affected,  they  should  be  elevated,  wrapped 
up,  and  the  arms  and  hands  warmed.  Massage  is  useful. 
When  gangrene  occurs,  dress  the  part  antiseptically  until  a 
line  of  demarcation  forms,  and  then  remove  the  dead  parts 
by  scissors,  forceps,  and  antiseptic  poultices.  If  amputation 
becomes  necessary,  which  will  rarely  be  the  case,  wait  for 
a  line  of  demarcation. 

Diabetic  gangrene  resembles  in  many  points  senile  gan- 
grene, but  the  dead  portions  remain  somewhat  moist  and 
putrefy.  Some  attribute  it  directly  to  sugar  in  the  blood. 
Some  think  the  tissues  are  simply  less  resistant  to  infection. 
Many  hold  that  it  is  of  neurotic  origin.  Heidenhain  be- 
lieves that  it  is  due  to  arterial  sclerosis.  Diabetic  gangrene 
is  most  usually  met  with  upon  the  feet  and  legs  of  elderly 
people,  but  it  may  arise  at  any  age  and  may  attack  the  gen- 
ital organs,  thigh,  lung,  buttock,  eye,  back,  finger,  or  neck 
(Hunt).  It  may  show  a  single  area,  may  show  several  areas, 
or  may  be  symmetrical.  It  may  arise  in  any  stage  of  dia- 
betes from  the  earliest  to  the  latest.  It  may  begin  as  a  per- 
forating ulcer,  and,  as  in  senile  gangrene,  a  trivial  injury  is 
apt  to  be  the  exciting  cause.  It  may  arise  without  any  ante- 
cedent injury.  When  the  gangrene  follows  a  traumatism  there 
are  no  prodromic  symptoms.  When  it  arises  spontaneously 
in  the  skin  it  is  often  preceded  by  pain  of  a  neuralgic  nature 
and  attacks  of  "  livid  or  violaceous  discoloration  of  the  skin, 
with  lowered  surface-temperature  and  sometimes  loss  of  sen- 
sation "  (Elliot).  This  gangrene  is  often  superficial,  but  may 
become  deep  if  it  follows  an  injury  or  ulcer.  The  gan- 
grenous area  is  somewhat  moist  as  a  rule,  but  may  be  dry. 
The  parts  about  are  livid  and  may  be  covered  with  vesicles. 
It  spreads  slowly,  but  more  rapidly  than  senile  gangrene. 
There  is  little  tendency  to  the  formation  of  any  line  of  de- 
marcation, although  occasionally  spontaneous  healing  occurs. 
Surgeons  have  become  shy  of  amputating  in  such  cases,  but 
the  experience  of  Kuster,  of  Berlin,  proves  conclusively  that 
an  amputation  should  be  performed  at  once  in  diabetic  gan- 
grene, and  should  be  done  above  the  knee.  If  we  operate 
below  the  knee,  the  flaps  will  become  gangrenous.  It  has 
been  noted  that  sugar  will  sometimes   disappear  from  the 


128  MODERN  SURGERY. 

urine  after  an  amputation.  Of  1 1  amputations  by  Kuster, 
6  recovered  and  5  died;  and  of  these  5,  3  had  albumin  in 
the  urine  as  well  as  sugar.^ 

Heidenhain  warmly  advocates  early  high  amputation,  with 
the  making  of  short  flaps.  When  the  patient  dies  after  ope- 
ration he  usually  does  so  in  coma.  In  any  case  after  opera- 
tion, or  in  any  case  not  operated  upon,  treat  the  diabetes  by 
means  of  drugs  and  diet.  Never  fail  to  examine  the  urine 
in  every  case  of  gangrene,  for  diabetes  might  be  present 
when  it  had  not  been  suspected.  Surgical  operations  upon 
diabetes  are,  of  course,  very  dangerous,  and  are  only  advised 
in  emergencies,  because  the  wound  is  apt  to  slough  and  coma 
may  arise. 

Gangrene  from  erg-otism  is  a  peripheral  dry  gangrene 
arising  from  tonic  vascular  contraction  produced  by  the  ergot 
in  bread  made  from  diseased  rye.  The  gangrene  is  preceded 
by  anesthesia,  muscular  cramp,  tingUng  pains,  itching,  and 
"  gradual  blood-stasis  in  certain  vascular  areas "  (Osier). 
This  form  of  gangrene  occurs  in  epidemics  where  rye-bread 
is  largely  used,  but  is  very  rare  in  the  United  States.  It 
usually  affects  the  fingers  or  toes,  but  may  involve  an  entire 
limb,  and  can  be  symmetrical.  In  acute  cases  death  occurs 
in  from  seven  to  ten  days.^  In  severe  chronic  cases  await  a 
line  of  demarcation  and  then  amputate.  In  superficial  cases 
dress  with  hot  antiseptic  fomentations  and  elevate  the  part, 
and  every  day  take  scissors  and  forceps  and  remove  the 
loose  crusts. 

Gangrene  from  Frost-bite. — When  parts  have  been  badly 
frozen  the  peripheral  portions  dry  up.  The  parts  are  deprived 
of  all  blood  because  of  contraction  of  the  vessels  and  because 
plasma  coagulates  at  a  few  degrees  above  freezing.  Cold 
disorganizes  the  blood,  breaking  up  white  corpuscles  with 
the  liberation  of  fibrin-ferment  and  the  subsequent  coagula- 
tion of  plasma,  and  destroying  red  corpuscles  with  the  libe- 
ration of  hemoglobin.  When  a  patient  so  afflicted  is  brought 
into  a  warm  atmosphere,  blood  cannot  run  into  the  dead 
part,  and  the  living  tissues  in  contact  with  it  inflame,  form- 
ing a  line  of  demarcation.  Hence  we  note  that  severe  frost- 
bite causes  dry  gangrene.  If  a  part  which  is  not  so  badly 
frozen  is  brought  suddenly  into  a  warm  atmosphere,  inflam- 
mation takes  place  when  the  blood  runs  into  the  frosted 
tissues,  and  moist  gangrene  results.  A  frost-bite  in  which 
the  skin  is  livid  and  not  as  yet  gangrenous  should  be  treated 

1  See  the  convincing  article  of  Chas.  A.  Powers  in  Amer.  Journal  of  Med. 
Sciences,  Nov.  ii,  1892.  '^  Pick,  in  Heath's  Surgical  Dictionary. 


iVORTIFICATION,    GANGRENE,    OR   SPHACELUS.        1 29 

by  frictions  with  snow  or  towels  soaked  in  iced  water.  As 
the  skin  becomes  warmer  and  congestion  disappears  the 
part  should  be  wrapped  in  cotton-wool.  A  sufferer  from 
frost-bite  should  not  suddenly  be  brought  into  a  warm  room. 
When  gangrene  follows,  if  only  small  areas  be  involved,  al- 
low the  dead  part  to  come  away  spontaneously,  applying  in 
the  meanwhile  hot  antiseptic  fomentations.  If  separation  be 
delayed  by  cartilage,  ligament,  or  bone,  cut  through  the  re- 
taining structure.  If  amputation  becomes  necessary,  await 
a  line  of  demarcation,  as  we  are  not  sure  how  high  tissue- 
damage  extends,  and  to  amputate  through  devitalized  parts 
would  mean  renewed  gangrene. 

Noma,  or  cancrum  oris,  is  a  gangrene  beginning  as  a 
sloughing  ulcer  on  the  gums  or  cheeks,  and  affecting  young 
children  who  live  amid  filth  and  squalor  or  who  are  conva- 
lescing from  acute  fevers.  This  disease  may  destroy  large 
portions  of  the  cheeks  and  jaws.  The  constitutional  symp- 
toms are  diarrhea,  fever,  and  great  exhaustion.  Death  is 
the  usual  result,  due  frequently  to  septic  bronchopneumonia 
(Bowlby).  Lingard  has  found  a  bacillus  which  he  believes 
is  causative  of  noma,  but  most  observers  consider  pus  organ- 
isms as  causative. 

The  treaUncnt  of  noma  consists  in  destruction  of  the  dis- 
eased tissue  by  nitric  acid  or  the  actual  cautery,  the  use,  lo- 
cally and  often,  of  peroxid  of  hydrogen  and  antiseptic  washes, 
and,  internally,  the  employment  of  nutritious  food,  stimulants, 
and  tonics.  After  arrest  of  the  gangrene  a  plastic  operation 
may  be  required. 

Sloughing  is  a  process  of  ulceration  by  which  visible 
portions  of  dead  tissue  are  separated.  These  visible  portions 
are  called  "  sloughs ;"  if  they  were  large,  they  would  be 
called  "  gangrenous  masses."  A  large  slough  is  a  gangre- 
nous mass ;  a  small  gangrenous  mass  is  a  slough  ;  there  is 
no  difference  in  the  process,  which  corresponds  to  the  forma- 
tion of  a  line  of  demarcation.  Sloughing  requires  thorough 
cleansing,  removal  of  the  sloughs,  and  antiseptic  treatment. 
Antiseptic  fomentations  are  applied  until  granulation  is  well 
advanced. 

Phagedena  is  a  process  (most  common  in  a  venereal 
sore)  in  which  the  surrounding  tissues  are  rapidly  eaten  up, 
the  sore  becoming  jagged  and  irregular,  with  a  sloughy  base 
and  thin  edges  ;  the  discharge  becoming  thin  and  reddish, 
and  the  encircling  tissues  becoming  deeply  congested.  This 
ulcer  has  no  tendency  to  heal.  It  is  due  to  a  specific  poison 
which  has  not  yet  been  isolated.  Nojua  viilvcs  is  a  form  of 
9 


130  MODERN  SURGERY. 

phagedena  which  attacks  the  genitals  of  Httle  girls  who  are 
unhealthy,  dirty,  or  convalescent  from  a  specific  fever. 

The  treatment  of  phagedena  consists  in  repeated  touch- 
ing with  tincture  of  chlorid  of  iron  and  the  local  use  of 
iodoform,  the  employment  of  continued  irrigation,  or  the 
application  of  the  cautery,  chemical  or  actual.  The  parts 
are  dressed  with  hot  antiseptic  fomentation.  Whatever  else 
is  done,  tonics,  stimulants,  and  nutritious  diet  must  be  given. 

Decubital  Gangrene,  or  Bed-sore.— A  bed-sore  is  the 
result  of  local  failure  of  nutrition  in  a  person  whose  tissues 
are  in  a  state  of  low  vitality  from  disease  or  from  injury. 
Such  sores  are  due  to  pressure,  aided  it  may  be  by  the  pres- 
ence of  urine,  of  feces,  and  of  sweat,  by  wrinkHng  of  the 
sheets,  or  the  dropping  of  foreign  bodies  (such  as  crumbs) 
in  the  bed.  These  ordinary  pressure-sores  arise  like  splint- 
sores  due  to  the  pressure  of  a  splint  upon  the  tissues  over  a 
bony  prominence.  They  occur  over  the  heels,  elbows, 
scapulae,  trochanters,  sacrum,  and  nucha.  The  pressure  in- 
terferes with  the  blood-supply,  the  weakened  tissues  inflame, 
vesication  occurs,  sloughs  form,  and  an  ugly  ulcer  is  ex- 
posed. 

The  acute  bed-sore  of  Charcot  is  seen  during  certain  dis- 
eases and  after  some  injuries  of  the  nervous  system.  These 
sores  are  usual  over  the  sacrum  in  acute  myelitis,  and  may 
appear  in  four  or  five  days  after  the  beginning  of  a  disease 
or  the  infliction  of  an  injury.  The  surgeon  sees  acute  bed- 
sores upon  the  buttock  of  the  paralyzed  side  after  brain- 
injuries,  and  over  the  sacrum  in  spinal  injuries.  Some  believe 
these  sores  are  due  to  vasomotor  disorder,  but  others,  notably 
Charcot,  attribute  them  to  disturbance  of  the  trophic  nerves 
or  centres. 

Treatment  of  Bed-sores. — The  "  ounce  of  prevention  " 
is  here  invaluable.  From  time  to  time,  if  possible,  alter  the 
position  of  the  patient,  keep  him  clean,  maintain  the  blood- 
distribution  of  the  skin  by  frequent  rubbing  with  alcohol 
and  a  towel,  and  keep  the  sheet  clean  and  smooth.  When 
congestion  appears  (paratrimma,  or  beginning  sore),  at  once 
use  an  air-cushion  or  a  water-bed  and  redouble  the  care  to 
frequently  change  the  position  of  the  patient.  Not  only 
protect,  but  also  harden,  the  skin.  Wash  the  part  twice 
daily  and  apply  spirits  of  camphor  or  glycerole  of  tannin ; 
or  rub  with  salt  and  whiskey  (3ij  to  Oj) ;  or  apply  a  mixture 
of  5ss  of  powdered  alum,  fgij  of  tincture  of  camphor,  and 
the  whites  of  four  eggs  ;  or  paint  with  corrosive  sublimate 
and  alcohol  (gr.  ij  to  3j) ;  or  apply  tannate  of  lead  or  equal 


MORTIFICATION,    GANGRENE,    OR   SPHACELUS.        I3I 

parts  of  oil  of  copaiba  and  castor  oil ;  or  paint  on  a  protective 
coat  of  flexible  collodion. 

When  the  skin  seems  on  the  verge  of  breaking,  paint  it 
with  a  solution  of  nitrate  of  silver  (gr.  xx  to  5j).  When 
the  skin  breaks,  a  good  plan  of  treatment  is  to  touch  once 
a  day  with  silver  solution  (gr.  x  to  5J)  and  cover  with  zinc- 
ichthyol  gelatin.  We  can  wash  the  sores  daily  with  i  :  2000 
corrosive-sublimate  solution,  dust  with  iodoform,  and  cover 
with  soap  plaster,  with  lint  spread  with  zinc  ointment,  or  with 
dry  aseptic  gauze.  When  sloughs  form,  cut  most  of  them 
off  with  scissors  after  cleaning  the  parts,  slit  up  sinuses,  and 
use  antiseptic  poultices.  In  sloughing  Dupuytren  employed 
pieces  of  lint  wet  with  lime-juice  and  dusted  the  sore  with 
cinchona  and  charcoal.  In  obstinate  cases  use  the  contin- 
uous hot  bath  or  the  intermittent  ice  poultice.  When  the 
sloughs  separate,  dress  antiseptically  or  with  equal  parts  of 
resin  cerate  and  balsam  of  Peru.  If  healing  is  slow,  touch 
occasionally  with  silver  solution  (gr.  x  to  5j).  Bed-sores, 
being  expressive  of  lowered  vitality,  demand  that  the  pa- 
tient shall  be  stimulated,  shall  be  well  nourished,  and  shall 
sleep  soundly. 

Postfebrile  Gangrene. — Dry  or  moist  gangrene  may 
follow  any  fever,  but  is  most  frequent  after  typhoid  (may 
follow  influenza,  measles,  scarlet  fever,  etc.).  Keen,  in  the 
Toner  lecture  for  1876,  collected  113  cases  of  postfebrile 
gangrene,  and  43  of  these  were  due  to  typhoid.  It  is  most 
usual  in  the  lower  extremities,  but  may  appear  in  the  upper 
extremities,  cheeks,  ears,  nose,  genitals,  lungs,  etc.  Some 
writers  have  assigned  as  the  cause  weakness  of  cardiac 
action,  but  most  observ^ers  believe  an  obstructing  clot  is  the 
usual  cause.  This  clot  is  secondary  to  endarteritis  due  to 
toxins  of  the  typhoid  bacillus.'^  It  most  often  appears  in  the 
third  week,  but  may  arise  far  into  convalescence.  Treatment 
presents  nothing  exceptional.  If  an  extremity  is  extensively 
involved,  await  a  line  of  demarcation  before  amputating. 

Rules  when  to  Amputate  for  Gangrene. — In  dry 
gangrene,  due  to  obstruction  of  a  non-diseased  artery,  wait 
for  a  line  of  demarcation.  In  senile  gangrene,  if  it  affect 
only  one  or  two  toes,  let  the  dead  parts  be  cast  off  sponta- 
neously. If  a  greater  area  is  involved  or  the  process 
spreads,  amputate  above  the  knee  without  waiting  for  the 
line.  In  ordhiary  moist  gangrene  wait  for  a  line  of  demar- 
cation. In  traumatic  spreading  gangrene  amputate  at  once. 
In  hospital  gangrene  and  in  Raynaitd's  gangrene  wait  for  a 

^  Mettler,  in  iVe-w  York  Med.  Joiir.,  March  9,  1895. 


132 


MODERN  SURGERY. 


line  of  demarcation.  In  diabetic  gangrene  amputate  at  once, 
high  up.  In  ergot  gangrene,  in  postfebrile  gangrene,  and  in 
frost  gangrene  wait  for  a  line  of  demarcation. 


IX.  THROMBOSIS   AND   EMBOLISM. 

Thrombosis  is  the  antemortem  coagulation  of  blood  in 
the  heart  or  in  a  vessel,  the  coagulum  remaining  at  its  point 
of  origin  and  plugging  up  the  vessel  partially  or  completely. 
This  process  is  an  essential  part  in  the  arrest  of  hemor- 
rhage ;  it  occurs  in  phlebitis  and  arte- 
ritis, and  affords  a  frequent  basis  for 
embolism.  Thrombi  may  form  in  the 
veins,  in  the  arteries,  and  in  the  heart. 
Clotting  is  due  to  destruction  of  white 
blood-cells,  fibrin-ferment  being  set  free, 
causing  the  union  of  calcium  and  fibrin- 
ogen and  thus  forming  fibrin.  Throm- 
bosis is  more  common  in  the  veins  than 
in  the  arteries,  the  slow  blood-current 
and  the  existence  of  valves  favoring  the 
deposit,  though  not  causing  it.  Fig.  35 
shows  thrombosis. 

Causes  of  Thrombus. — The  essential 
cause  of  all  intravascular  thrombi  is 
damage  to  the  endothelial  coat,  though 
many  other  conditions  favor  their  formation.  Among  these 
favoring  conditions  are  retarded  circulation  in  tuberculosis, 
influenza,  and  fevers,  the  blood  clotting  behind  the  vein- 
valves  after  the  endothelium  has  been  damaged  by  toxins  ; 
or  the  pressure  of  a  bandage  or  of  a  splint ;  varicose  veins ; 
ligation  of  a  vessel ;  injuries  of  a  vessel ;  foreign  bodies  in  a 
vessel ;  atheroma  in  arteries  ;  sutures  in  a  vessel ;  certain  dis- 
eases, such  as  gout,  typhoid  fever,  pregnancy,  and  septic 
processes ;  phlebitis  or  arteritis  arising  in  the  vessel  or  from 
extension  of  surrounding  inflammation  ;  and  entrance  of  spe- 
cific organisms. 

It  has  been  asserted  that  so  long  as  the  endothelium  of  a 
vessel  is  uninjured  a  clot  does  not  form.  Slowing  of  the 
blood-current  in  aseptic  conditions,  it  is  now  taught,  will 
not  cause  thrombosis.  One  of  the  functions  of  the  endo- 
thelial coat  is  to  keep  the  blood  fluid  by  preventing  corpus- 
cular disintegration.  A  thrombus  can  form  only  v/hen  fibrin- 
ferment  is  set  free,  and  fibrin-ferment  can  be  set  free  only 
when  white  corpuscles  disintegrate.     When  moving  blood 


Fig.  35. — Thrombus  in  the 
saphenous  vein  (Green). 


THROMBOSIS  AND   EMBOLISM.  I  33 

coagulates,  the  third  corpuscles  first  settle  out,  and  then  the 
leukocytes.  This  is  known  as  the  white  or  "  antemortem  " 
thrombus — the  clot  of  moving  blood.  Thrombi  from  mov- 
ing blood  are  rarely  pure  white  :  they  contain  some  red  cor- 
puscles, forming  mixed  thrombi.  The  red  thrombus  plugs 
vessels  which  are  cut  across  or  ligated ;  it  also  occurs  in  sep- 
tic processes,  and  is  formed  after  death.  A  thrombus  may 
be  absorbed,  first  embryonic  tissue  and  then  fibrous  tissue  re- 
placing it  (organization).  A  thrombus  may  degenerate  and 
break  down  (fatty  degeneration),  giving  rise  to  emboli.  A 
thrombus  may  calcify  or  may  undergo  purulent  liquefaction, 
infective  emboli  being  set  free.  A  thrombus  in  an  artery 
is  apt  to  extend  to  the  first  collateral  branch,  but  does  not 
pass  higher.  The  blood-current  into  the  branch  prevents 
further  extension.  Remember  this  fact  when  an  artery  is 
cut  near  a  large  branch.  If  we  simply  tie  the  artery,  such  a 
short  clot  will  be  formed  that  the  vessel  will  not  be  oblit- 
erated. Tie  not  only  the  artery,  but  also  the  branch.  A 
clot  in  a  vein  may  extend  a  long  distance.  The  author  has 
seen  in  a  postmortem  examination  a  venous  thrombus  reach- 
ing from  the  ankle  to  the  vena  cava. 

Symptoms. — The  symptoms  are  dependent  on  the  seat 
of  the  obstruction.  An  organ  or  a  part  of  an  organ  may 
exhibit  functional  aberration.  The  local  signs  in  a  vessel 
accessible  to  touch  or  sight  are  the  presence  of  a  clot ;  if  it 
be  an  artery,  anemia  and  the  absence  of  pulse  below  the 
clot ;  if  it  be  a  vein,  swelling  and  edema  below  it.  There  is 
usually  pain  at  the  seat  of  trouble,  and  anesthesia  below  it. 
Moist  gangrene  may  follow  venous  thrombosis,  and  dry  gan- 
grene arterial  thrombosis.  Thrombophlebitis  is  inflammation 
of  a  vein  in  which  a  septic  thrombus  forms.  We  see  this 
condition  sometimes  in  the  lateral  sinus  of  the  brain  as  a 
result  of  suppuration  in  the  middle  ear;  in  any  of  the  cere- 
bral sinuses  after  compound  fracture  of  the  skull ;  and  in  the 
uterine  veins  in  puerperal  sepsis.  It  is  the  first  step  in  pye- 
mia. Thrombo-arteritis  is  inflammation  of  an  artery  in  which 
a  septic  thrombus  forms  or  in  which  a  septic  embolus  lodges. 
It  occasionally  attacks  an  aneurysmal  sac. 

Treatment. — If  in  a  limb,  raise  the  limb  a  few  inches  from 
the  bed,  keep  it  perfectly  quiet  to  avoid  detachment  of  frag- 
ments (emboli),  paint  with  iodin  or  rub  with  ichthyol,  apply 
a  bandage  from  the  toes  up,  and  place  hot  bottles  around 
the  extremity.  The  great  danger  is  the  formation  of  emboli, 
so  avoid  movements  and  rough  handling.  In  thrombophle- 
bitis, if  the  vessel  is  accessible,  tie  it  above  and  below  the 


134 


MODERN  SURGERY. 


clot,  open  the  vessel,  remove  the  clot,  irrigate,  and  pack  with 
iodoform  gauze.  Internally  the  treatment  is  stimulant  and 
supporting.  Massage  is  unsafe.  In  thrombo-arteritis  treat 
as  in  thrombophlebitis. 

^^mbolism  signifies  vascular  plugging  by  a  foreign  body 
(usually  a  blood-clot)  which  has  been  brought  from  a  dis- 
tance. Emboli  may  arise  either  in  the  venous  or  in  the 
arterial' system,  but  lodge  only  in  an  artery  or  in  the  veins 
of  the  liver.  The  initial  thrombus  may  form  upon  diseased 
heart-valves  or  in  a  vein.  It  may  be  composed  of  fat,  mi- 
cro-organisms, air,  or  a  portion  of  a  tumor.  An  embolus  is 
arrested  when  it  reaches  a  vessel  whose  diameter  is  less  than 
its  own.  It  is  usually  caught  just  above  a  bifurcation. 
When  an  embolus  lodges,  it  at  once  partially  or  entirely 
obstructs  the  circulation,  and  increases  in  size  by  throm- 
bosis. A  non-septic  embolus  usually  organizes.  A  soft 
embolus  may  disintegrate  and  permit 
of  re-establishment  of  the  circulation. 
An  embolus  may  cause  an  aneurysm. 
A  septic  embolus  breaks  down,  forms 
a  metastatic  abscess,  and  sends  other 
emboli  onward.  Fig.  36  shows  an 
impacted  embolus. 

An  embolus  is  more  serious  than  a 
thrombus :  it  causes  sudden  plugging 
which  makes  dangerous  anemia  inevit- 
able, and  it  may  produce  gangrene  if 
the  collateral  circulation  fails.  In 
organs  with  terminal  arteries  (spleen, 
kidney,  brain,  and  lung)  there  is  no 
collateral  circulation  and  embolism  causes  infarction.  The 
embolus  produces  an  area  of  anemia ;  the  removal  of  all 
propulsion  upon  the  venous  blood  causes  it  to  flow  back 
and  stagnate,  and  vascular  elements  exude,  forming  a  wedge- 
shaped  area  of  red  tissue,  the  embolus  being  the  apex  of 
the  wedge.  This  is  known  as  the  "  red  infarction,"  and  is 
often  seen  in  the  lung.  The  white  infarction  seen  in  the 
brain  and  kidney  is  not  due  to  retrogression  of  venous  blood, 
but  is  due  to  anemia  and  resulting  coagulation-necrosis.  A 
septic  embolus  causes  septic  arteritis  and  a  septic  infarction, 
and  a  septic  infarction  suppurates  and  forms  a  pyemic 
abscess. 

Symptoms. — The  symptoms  depend  upon  the  organ  in- 
volved. They  are  sudden  in  onset,  and  consist  of  loss  of 
function  which  may  be  permanent  or  which  may  be  followed 


Fig.  36. — Embolus  impacted 
at  bifurcation  of  a  branchi  of  the 
pulmonary  artery  (Green). 


THROMBOSIS  AND   EMBOLISM.  I  35 

by  inflammation  or  softening.  Embolism  of  the  cerebral 
arteries  may  cause  aphasia,  paralysis,  or  coma.  Embolism 
of  the  pulmonary  artery  may  cause  almost  instant  death. 
Embolism  of  the  central  artery  of  the  retina  causes  blindness. 
Embolism  of  a  large  artery  of  a  limb  produces  symptoms 
identical  with  thrombus,  except  more  sudden  and  decided. 

Treatment. — The  treatment  of  aseptic  embolism  depends 
upon  the  part  involved.  In  a  limb,  keep  the  part  warm  in 
order  to  stimulate  the  collateral  circulation,  elevate  several 
inches  from  the  bed,  and  insist  on  perfect  quiet.  Massage 
is  unsafe.  If  gangrene  ensues,  await  a  line  of  demarcation 
and  amputate.  In  septic  arteritis  in  an  accessible  region  it 
would  be  good  surgery  to  act  as  in  thrombo-arteritis  from 
thrombosis.  Unfortunately,  such  a  condition  is  not  often  in 
an  accessible  region.  After  an  operation  upon  veins  (as  the 
operation  for  varicocele  or  for  hemorrhoids),  after  a  cutting 
operation,  and  after  fracture,  avoid  as  much  as  possible  move- 
ments or  handling,  as  fragments  of  thrombus  may  be  de- 
tached. Operations  upon  the  rectum  may  be  followed  by 
hepatic  embolism  and  abscess  of  the  liver. 

Fat-embolism  is  an  accumulation  in  the  capillaries  of 
liquid  fat  after  injuries  of  adipose  tissue,  high  tension  forcing 
the  fat  into  the  open  mouths  of  veins.  Some  little  fat  may 
get  into  the  blood  by  means  of  the  lymphatics.  Fat-em- 
bolism occasionally  arises  in  osteomyelitis,  after  extensive 
bruises,  crushes,  or  lacerations,  and  after  amputations,  frac- 
tures, resections,  or  rupture  of  the  liver.'  This  fluid  fat  ac- 
cumulates especially  in  the  capillaries  of  the  lung  and  brain. 

Symptoms. — The  symptoms  are  those  of  edema  of  the 
lungs  and  exhaustion,  often  with  coma  or  delirium.  There 
are  restlessness,  dyspnea,  rapid  pulse  and  respiration,  and  low 
temperature.  If  life  is  prolonged  a  day  or  two,  oil  is  found 
in  the  urine.  Small  amounts  of  oil  may  be  found  in  the  urine 
after  serious  injuries  or  operations  when  no  symptoms  of 
embolism  exist.  Nevertheless,  the  presence  of  the  oil  is 
always  an  ominous  sign,  and  is  often  a  w^arning.  These 
symptoms  never  occur  until  at  least  twenty-four  hours  after 
the  accident,  and  rarely  before  the  third  day.  The  symptoms 
occur  at  a  later  period  than  those  of  shock,  and  at  an  earlier 
period  than  those  of  ordinary  embolism  of  the  lung.  Severe 
cases  are  commonly  fatal ;  milder  cases  are  often  recovered 
from. 

Treatment. — The  treatment  consists  of  the  ordinary  meth- 
ods used  in  shock — stimulants,  heat,  etc.,  with  dry  cupping 
1  G.  H.  Makins,  in  Heath's  Dictionary. 


136  MODERN  SURGERY. 

of  the  chest,  the  use  of  diuretics,  strychnin,  digitalis,  and,  it 
may  be,  artificial  respiration.  See  that  drainage  of  the  wound 
is  free,  if  an  external  wound  exists,  and  thoroughly  immobil- 
ize the  damaged  part.  In  order  to  prevent  fat-embolism  after 
a  severe  injury  insist  on  rest.  Massage  used  early  after  some 
injuries  is  dangerous,  as  it  may  force  fluid-fat  into  the  vessels. 
When  a  severe  contusion  gives  rise  to  a  large  cavity  filled 
with  blood  Groube  advises  incision,  to  lessen  the  danger  of 
fat-embolism.' 

X.   SEPTICEMIA  AND  PYEMIA. 

Septicemia,  or  sepsis,  is  a  febrile  malady  due  to  the  in- 
troduction into  the  blood  of  septic  organisms  or  their  prod- 
ucts. There  is  no  one  special  causative  organism,  and  any 
microbe  which  produces  inflammatory  and  febrile  products 
may  cause  it.  Either  streptococci  or  staphylococci  may  be 
present.  Septicemia  arises  by  absorption  of  septic  matter  by 
the  lymphatics.  CHnically  we  make  two  forms  of  septicemia  : 
(i)  sapremia,  septic  or  putrid  intoxication  ;  and  (2)  septic  in- 
fection, true  or  progressive  septicemia.  In  these  conditions 
the  area  of  infection  is  usually  discovered  by  the  surgeon, 
but  when  it  is  not  located  the  case  is  called  by  the  Germans 
cryptogenetic  septicemia. 

Sapremia,  or  septic  intoxication,  is  due  to  the  absorp- 
tion of  poisonous  ptoma'ins  from  a  putrefying  area.  The  bac- 
teria rarely  enter  the  blood,  but  their  toxins  do,  and,  as  these 
toxins  are  active  poisons,  the  condition  is  comparable  to 
poisoning  by  successive  alkaloidal  injections,  the  symptoms 
and  prognosis  depending  upon  the  dose.  Even  if  some  of 
the  organisms  enter  the  blood,  they  do  not  multiply  in  this 
fluid.  Slight  symptoms  and  recovery  follow  a  small  dose ; 
grave  symptoms  and  death  follow  a  large  one.  The  poison 
does  not  multiply  in  the  blood,  and  a  drop  of  the  blood  of  a 
person  laboring  under  putrid  intoxication  will  not  produce 
the  disease  when  introduced  into  the  blood  of  a  well  person  ; 
in  other  words,  the  disease  is  not  infective.  Sapremia  results 
from  the  absorption  of  putrid  matter  from  considerable  areas 
which  are  under  high  pressure.  It  may  follow  labor  where 
putrid  fluid  is  retained  in  the  womb,  or  follow  amputation 
where  decomposing  blood-clot  or  wound-fluid  is  pent  up 
within  the  flaps.  In  this  condition  there  always  exist  a  con- 
siderable absorbing  surface  and  a  large  amount  of  dead  mat- 
ter which  has  become  putrid.    Roswell  Park  points  out^  that 

1  Rev.  de  Chir.,  July,  1895. 

^  Treatise  on  Surgery  by  Avierican  Authors. 


SEPTICEMIA    AND   PYEMIA.  I  37 

saprcmia  arises  from  putrefaction  of  a  blood-clot  or  from 
wound-fluids  which  are  retained  like  foreign  bodies  in  the 
tissues,  and  does  not  arise  from  putrefaction  of  the  tissues 
themselves.  He  speaks  of  the  condition  as  due  to  the  ab- 
sorption of  poison  from  a  "  putrid  suppository."  We  use 
the  term  putrefaction  because  this  is  the  usual  change,  but 
any  fermentative  organism  may  cause  the  disorder.  Sapre- 
mia  is  a  malignant  form  of  surgical  fever,  and  its  existence 
means  an  ill-drained  wound,  and  a  fermenting  and  probably 
putrid  collection  of  blood-clot  or  wound-fluid. 

Symptovis. — In  twenty-four  hours  or  more  after  labor, 
after  an  injury,  or  after  an  operation,  there  is  a  chill  followed 
by  high  temperature,  gastric  disturbance,  dry  tongue,  weak, 
rapid  pulse,  great  prostration,  muscular  twitching,  restless- 
ness, headache,  often  delirium,  diarrhea,  foulness  of  wound, 
often  drying  up  of  wound-discharge,  diminution  or  suppres- 
sion of  urine,  and  a  strong  tendency  to  congestion  of  various 
organs.  Blood-examination  shows  leukocytosis.  Great  ele- 
vation of  temperature  precedes  death. 

Trcat7nent. — The  treatment  is  to  at  once  drain  and  asep- 
ticize the  putrid  area  and  give  enormous  doses  of  alcohol. 
Strychnin  and  digitalis  are  useful.  Purge  the  patient,  and 
favor  diaphoresis,  using  in  some  cases  the  hot  bath.  Estab- 
lish the  action  of  the  kidneys  ;  allay  vomiting  by  champagne, 
cracked  ice,  calomel,  cocain,  or  carbolic  acid  with  bismuth. 
Give  food  every  three  hours.  Feed  on  milk,  milk  and  lime- 
water,  liquid  beef-peptonoids,  and  other  concentrated  foods. 
Use  quinin  in  stimulant  doses.  Antipyretics  are  useless. 
Watch  for  any  visceral  congestion,  and  treat  it  at  once.  The 
use  of  saline  fluid  by  hypodermoclysis  or  venous  transfusion 
dilutes  the  poison  and  stimulates  the  heart,  skin,  and  kidneys 
to  activity. 

Septic  infection,  or  true  septicemia,  is  a  true  infective 
process.  In  sapremia  the  blood  contains  toxins  of  fermenta- 
tive organisms,  but  not  the  organisms  themselves.  In  septic 
infection  the  blood  contains  both  pyogenic  toxins  and  multi- 
plying pyogenic  organisms.  In  sapremia  the  causative  con- 
dition is  putrid  material  lodged  like  a  foreign  body  in  the 
tissues.  In  septic  infection  the  tissues  themselves  are  suppu- 
rating, and  both  bacteria  and  toxins  are  being  absorbed  by 
the  lymphatics.  Of  course,  septic  infection  may  be  associated 
with  septic  intoxication  or  may  follow  it.  In  suppurative  fever 
the  tissues  suppurate,  but  only  the  pyogenic  toxins  are  ab- 
sorbed, and  not  the  pyogenic  organisms.  In  septic  infection 
both  the  pyogenic  bacteria  and  toxins  enter  the  blood,  and 


138  MODERN  SURGERY. 

the  bacteria  multiply  in  the  blood  and  produce  continually- 
increasing  amounts  of  poison.  The  symptoms  of  sapremia 
depend  on  the  dose.  In  septic  infection  only  a  small  number 
of  organisms  may  get  into  the  blood,  but  they  multiply  enor- 
mously. The  pus  microbes  cause  true  septicemia,  and  reach 
the  blood  chiefly  through  the  lymphatics,  but  to  some  degree 
by  penetrating  the  walls  of  vessels.  A  drop  of  blood  from  a 
man  with  septic  infection  will  reproduce  the  disease  when  in- 
jected into  the  blood  of  an  animal;  hence  it  is  a  true  infective 
disease.  The  wound  in  such  cases  is  often  small,  and  is 
commonly  punctured  or  lacerated. 

Symptoms. — The  type  of  this  condition  is  met  with  in 
puerperal  septicemia  or  in  an  infected  wound.  It  begins,  in 
from  four  to  seven  days  after  labor  or  an  injury,  with  a  chill, 
which  is  followed  by  fever,  at  first  moderate,  but  soon  be- 
coming high.  The  fever  presents  morning  remissions  and 
evening  exacerbations,  and  may  occasionally  show  an  inter- 
mission. When  the  remission  begins  there  is  a  copious 
sweat.  The  pulse  is  small,  weak,  very  frequent,  and  com- 
pressible. The  tongue  is  dry  and  brown  with  a  red  tip. 
The  vomiting  is  frequent,  and  diarrhea  is  the  rule.  Delirium 
alternates  with  stupor,  and  coma  is  usual  before  death. 
Prostration  is  very  great.  Toward  the  end  the  face  often 
becomes  Hippocratic.  Visceral  congestions  occur.  The 
spleen  is  enlarged,  ecchymoses  and  petechiae  are  noted, 
secretions  dry  up,  urinary  secretion  is  scanty  or  is  sup- 
pressed, and  the  wound  becomes  dry  and  brown.  Blood- 
examination  detects  disintegration  of  red  globules,  and 
marked  leukocytosis.  When  a  wound  inaugurates  septi- 
cemia, red  lines  of  lymphangitis  are  seen  about  it  and  there 
is  enlargement  of  related  lymphatic  glands.  No  thrombi 
or  emboli  exist  in  septicemia.  The  prognosis  is  bad,  and 
in  some  malignant  cases  death  occurs  within  twenty-four 
hours. 

The  treatment  is  the  same  as  for  septic  intoxication.  An- 
tistreptococcic serum  is  employed  by  some  surgeons,  but  the 
value  of  this  method  is  as  yet  doubtful. 

Pyemia. — Pyemia  is  a  condition  in  which  metastatic  ab- 
scesses arise  as  a  result  of  the  existence  of  septic  thrombo- 
phlebitis, the  disease  being  characterized  by  fever  of  an  in- 
termittent type  and  by  recurring  chills.  It  is  not  actually 
due  to  free  pus  in  the  blood,  but  to  the  passage  into  the 
blood  of  clots  infected  by  streptococci  and  staphylococci. 
If  an  area  of  infection  leads  to  thrombophlebitis,  lymphatic 
absorption  of  toxins  or  organisms  is  apt  to  be  occurring  at 


SEPTICEMIA   AND   PYEMIA.  1 39 

the  same  time.  Hence  in  many  cases  septicemia  exists  with 
pyemia. 

In  an  area  of  suppuration  there  are  coagulation-necrosis, 
thrombosis,  and  septic  inflammation  of  the  adjacent  vessels, 
and  the  thrombi  are  infected.  A  vessel-thrombus  runs  up 
in  the  lumen  of  a  vein,  and  the  apex  of  the  purulent  clot 
softens,  a  portion  of  it  is  broken  off  by  the  blood-stream  and 
carried  as  an  embolus  into  the  circulation.  Many  of  these 
poisonous  emboli  enter  into  the  blood  and  lodge  in  some 
vessels  which  are  too  small  to  transmit  them,  and  at  their 
points  of  lodgement  form  embolic,  secondary,  or  metastatic 
abscesses.  Wounds  of  the  superficial  parts  and  bones  pro- 
duce pyemic  infarctions  and  metastatic  abscesses  of  the  lungs. 
When  these  infarctions  break  into  fragments  particles  may 
return  to  the  heart  and  lodge,  or  may  be  sent  out  through 
the  arterial  system  to  form  other  foci  in  distant  organs.  In- 
fected areas  connected  with  the  portal  circulation  (intestinal 
injuries  or  suppurating  piles)  produce  abscess  of  the  liv^er. 
Malignant  endocarditis  is  called  "  arterial  pyemia,"  and  is 
due  to  endocardial  embolic  infection.  In  this  disorder  in- 
fected emboli  lodge  in  the  kidneys,  the  spleen,  the  alimen- 
tar}'  tract,  the  brain,  or  the  skin  (Osier).  Idiopathic  pyemia 
is  a  misnomer.  Some  primar}-  focus  of  infection  must  exist 
(often  in  the  middle  ear). 

Symptoms. — The  wound  becomes  dr>',  brown,  and  offen- 
sive. A  severe  and  prolonged  chill  or  a  succession  of  chills 
ushers  in  the  disease ;  high  fev^er  follows,  and  drenching 
sweats  occur.  The  chills  recur  every  other  day,  every  day, 
or  oftener.  After  the  sweat  the  temperature  falls  and  may 
become  nearly  normal.  The  temperature  often  oscillates 
violently.  The  general  symptoms  of  vomiting,  wasting,  etc., 
resemble  those  of  septicemia.  In  some  cases  the  mind 
remains  clear,  in  many  the  delirium  is  purely  nocturnal. 
The  skin  becomes  jaundiced,  and  a  profound  adynamic 
state  is  rapidly  established.  The  blood  shows  disintegra- 
tion of  red  corpuscles  and  leukocytosis.  The  spleen  is 
enlarged.  The  lodgement  of  emboli  produces  symptoms 
whose  nature  depends  upon  the  organ  involved.  Lodge- 
ment in  the  lungs  causes  shortness  of  breath  and  cough, 
with  slight  physical  signs.  Lodgement  in  the  pleura  or  peri- 
cardium gives  pronounced  physical  evidence.  Lodgement  in 
the  spleen  produces  severe  pain  and  great  enlargement.  The 
parotid  gland  not  unusually  suppurates  (as  in  the  case  of 
President  Garfield). 

In  a  suspected  case  of  pyemia  always  look  for  a  wound, 


140  MODERN  SURGERY. 

and  if  this  does  not  exist,  remember  that  the  infection  may 
arise  from  gonorrhea,  osteomyehtis,  suppuration  in  the 
middle  ear,  or  abscess  of  the  prostate.  Chronic  pyemia 
may  last  for  months ;  acute  pyemia  may  prove  fatal  in  three 
days.  The  complications  are  joint-suppuration,  broncho- 
pneumonia, pleuritis,  endocarditis,  pericarditis,  peritonitis, 
pyelitis,  venous  thrombosis,  and  abscesses. 

Treatment  is  the  same  as  for  septicemia.  Open,  drain,  and 
asepticize  any  wound  and  any  accessible  secondary  abscess. 

XI.  ERYSIPELAS   (ST.  ANTHONY'S   FIRE). 

il^rysipelas  is  an  acute,  contagious,  spreading  capillary 
lymphangitis  due  to  the  streptococcus  of  erysipelas,  which 
grows  and  multiplies  in  the  smaller  lymph-channels  of  the 
skin  and  its  subcutaneous  cellular  layers  and  of  serous  and 
mucous  membranes.  The  disease  is  characterized  by  a  rap- 
idly spreading  dermatitis,  by  a  remittent  fever  due  to  ab- 
sorption of  toxins,  and  by  a  tendency  to  recur.  It  is  al- 
ways due  to  a  wound.  Idiopathic  erysipelas  is  due  to  a 
small  wound  which  escapes  notice.  The  involved  area  may 
or  may  not  suppurate.  Suppuration,  some  say,  does  not 
require  a  mixed  infection,  as  the  streptococcus  is  identical 
with  the  streptococcus  pyogenes  (Osier,  Koch) ;  others  think 
suppuration  does  require  mixed  infection,  as  they  believe 
the  streptococcus  is  not  pyogenic.  Erysipelas  is  most 
common  in  the  spring  and  fall,  and  is  most  usually  met 
with  among  those  who  are  crowded  into  dark,  dirty,  and 
ill-ventilated  quarters  ;  it  attacks  by  preference  the  debilitated 
and  broken-down  (as  alcoholics  and  sufferers  from  Bright's 
disease).  The  disease  may  become  endemic  in  special  places 
or  localities.  The  poison  of  erysipelas  will  produce  puer- 
peral fever  in  a  lying-in  woman.  The  streptococcus  was 
first  obtained  in  pure  cultures  by  Fehleisen  (Tillmann's 
Principles  of  Surgery).  This  organism  is  widely  diffused. 
The  question  of  identity  with  the  streptococcus  pyogenes 
is  discussed  on  p.  38. 

Forms  of  Erysipelas. — Ambulant,  erratic,  migratory,  or 
wandering  erysipelas  is  a  form  which  tends  to  spread  wide- 
ly over  the  body,  leaving  one  part  and  going  to  another. 
Bidlous  erysipelas  is  attended  by  the  formation  of  bullae. 
In  diffused  erysipelas  the  borders  of  the  inflammation  grad- 
ually merge  into  healthy  skin.  Erythematous  erysipelas 
involves  the  skin  superficially.  Metastatic  erysipelas  appears 
in  various  parts  of  the  body.     Puerperal  erysipelas  begins 


ERYSIPELAS.  I4I 

in  the  genitals  of  lying-in  women,  producing  puerperal 
fever.  Eiysipclas  simplex  is  the  ordinary  cutaneous  form. 
Erysipelas  ncotiatoruvi  begins  in  the  unhealed  navel  of  a 
newborn  child  and  spreads  from  this  point.  Typhoid  er\'- 
sipelas  occurs  with  profound  adynamia.  Universal  er>'sip- 
elas  involves  the  entire  body.  Cellulitis  is  erysipelas  of  the 
subcutaneous  layers.  PJilegmonoiis  erysipelas  involves  the 
skin  and  subcutaneous  tissues,  and  causes  suppuration,  and 
often  gangrene.  Edematous  erysipelas  is  a  variety  of  phleg- 
monous erysipelas  with  enormous  subcutaneous  edema. 
LympJiatic  erysipelas  is  characterized  by  rose-red  lines  of 
lymphangitis.  Venous  erysipelas  is  marked  by  the  dark 
color  of  venous  congestion.  Mucous  erysipelas  involves  a 
mucous  membrane.  Erysipelas  may  attack  the  fauces,  pro- 
ducing a  very  grave  condition. 

Clinical  Forms. — The  clinical  forms  are  cutaneous  er\'sip- 
elas,  cellulocutaneous  or  phlegmonous,  cellulitis,  and  mucous 
erysipelas. 

Cutaneous  erysipelas  most  frequently  attacks  the  face. 
A  fever  suddenly  appears,  rises  rapidly,  reaches  a  consider- 
able height,  and  at  the  time  of  febrile  onset  spots  of  redness 
appear  on  the  skin.  These  spots  run  together,  and  a  large 
extent  of  surface  is  found  to  be  red  and  a  little  elevated. 
Any  wound,  ulcer,  or  abrasion  which  exists  becomes  dry 
and  unhealthy,  and  its  edges  redden  and  swell.  This  com- 
bination of  redness  and  swelling  extends,  and  its  area  is 
sharply  defined  from  the  healthy  skin.  The  color  fades  at 
once  on  pressure  and  returns  at  once  when  pressure  is 
removed.  In  the  hyperemic  area  vesicles  or  bullae  form, 
containing  first  serum  and  later  it  may  be  sero-pus.  Edema 
affects  the  subcutaneous  tissues,  producing  great  swelling  in 
regions  where  they  are  lax  (as  in  the  eyelids).  The  anatom- 
ically related  lymphatic  glands  become  large  and  tender,  and 
between  them  and  a  wound  are  often  seen  the  red  lines  of 
inflamed  lymphatic  vessels.  In  an  ordinarily  strong  person 
the  color  is  bright  red  or  more  rarely  dark  red.  A  dusky 
color  precedes  suppuration.  A  blue  color  precedes  gan- 
grene or  indicates  profound  cardiac  and  pulmonar}'  involve- 
ment. There  is  slight  burning  pain  in  er)'sipelas  which  is 
increased  by  pressure.  Erysipelas  spreads  at  its  periphery 
and  fades  at  its  point  of  origin.  It  spreads  now  in  one  direc- 
tion, now  in  another,  influenced,  according  to  Pfleger,  by  the 
furrows  of  the  skin.  When  spreading  stops  the  swelling 
and  redness  gradually  abate,  and  after  they  disappear  des- 
quamation   takes    place,   and    the    blebs    become    dry    and 


142  MODERN  SURGERY. 

crusted.  Cutaneous  erysipelas  rarely  suppurates,  but  may 
do  so.  The  fever  is  remittent,  and  usually  terminates  in 
four  or  five  days  by  crisis. 

In  strong  subjects  the  symptoms  are  usually  slight.  In 
the  old  or  debilitated  the  symptoms  are  typhoid,  dehrium 
comes  on,  and  death  is  usual.  Possible  complications  are 
meningitis,  pneumonia,  septicemia,  pleuritis,  pyemia,  endo- 
carditis, and  albuminuria.  Erysipelas  neonatorum  is  gen- 
erally fatal.  In  some  instances  an  attack  of  erysipelas  will 
cure  an  old  skin  eruption,  a  new  growth,  an  ulcer,  or  an  area 
of  lupus.  This  is  the  erysipele  salutaire  of  our  French 
confreres  (p.  230). 

Treatment. — Isolate  the  patient,  asepticize  any  wound,  and 
give  a  purge.  Cases  of  cutaneous  erysipelas  tend  to  get 
well  without  treatment.  If  a  person  is  debilitated,  stimu- 
late freely.  Tincture  of  chlorid  of  iron  and  quinin  are 
usually  administered.  Nutritious  food  is  important.  For 
sleeplessness  or  delirium  use  chloral  or  the  bromids ;  for 
high  temperature,  cold  sponging  and  antipyretics.  To  pre- 
vent spreading  some  have  advised  injection  of  the  healthy 
skin  near  the  blush  with  a  2  per  cent,  carbolic  solution  or 
with  gr.  ^  of  corrosive  sublimate.  Locally,  paint  the  in- 
flamed area  with  equal  parts  of  iodin  and  alcohol  and  apply 
lead-water  and  laudanum.  If  an  extremity  be  involved, 
bandage  it.  Another  good  apphcation  is  a  50  per  cent,  ich- 
thyol  ointment  with  lanolin.  A  very  useful  method  is  Von 
Nussbaum's.  The  author  applies  it  somewhat  modified,  as 
follows  :  wash  with  ethereal  soap,  irrigate  with  a  solution  of 
corrosive  sublimate  (i  :  looo),  dry  with  a  sterile  towel,  apply 
an  ointment  of  ichthyol  and  lanolin  (50  per  cent.),  and  dress 
with  antiseptic  gauze.  Some  use  iced-water  cloths  and  some 
prefer  hot  fomentations.  Others  apply  borated  talc  or  sali- 
cylated  starch.  Ringer  advised  painting  every  three  hours 
with  a  mixture  composed  of  gr.  xxx  of  tannic  acid,  gr.  xxx 
of  camphor,  and  .^iv  of  ether.  J.  M.  Da  Costa  recommends 
pilocarpin  internally  in  the  beginning  of  a  case.  Antistrepto- 
coccic serum  has  been  used  in  erysipelas,  and  great  results 
have  been  claimed  for  it.  Roger  and  Charrin's  serum  may 
be  used.  The  dose  is  30  c.cm.  It  is  asserted  that  under  its 
influence  the  temperature  soon  becomes  normal.  We  have 
had  no  personal  experience  with  the  serum  treatment. 

Cellulocutaneous  or  phlegmonous  erysipelas  is  charac- 
terized by  high  temperature  (i04°-io6°),  the  rapid  onset  of 
grave  prostration,  irregular  chills,  sweats,  and  a  strong  ten- 
dency to  delirium.     The  parts  are  not  so  red  as  in  the  pre- 


ERYSIPELAS.  1 43 

ceding  form,  but  the  tumefaction  is  vastly  greater ;  it  is 
brawny,  comes  on  early  and  with  exceeding  rapidity,  induc- 
ing a  high  degree  of  tension  and  frequently  producing  slough- 
ing or  even  cutaneous  gangrene.  The  lymphatic  glands  are 
swollen,  but  the  inflamed  lymphatic  vessels  are  hidden  by 
the  tumefaction.  In  most  cases  suppuration  occurs,  and 
when  this  happens  the  parts  become  boggy.  When  the 
disease  abates  sloughs  form,  which  leave  ulcers  upon  being 
thrown  off  In  bad  cases  muscles,  vessels,  tendons,  and 
fascia  may  slough  away.  The  commonest  complications  are 
suppression  of  urine,  bronchopneumonia,  congestion  and 
edema  of  the  lungs,  meningitis,  congestion  of  the  kidneys, 
and  acute  pleurisy.  We  see  this  form  of  erysipelas  some- 
times after  extravasation  of  urine.  It  is  not  a  pure  strepto- 
coccus infection.  There  is  a  mixed  infection  with  other  pyo- 
genic cocci,  and  often  with  organisms  of  putrefaction. 

Treatment. — At  once  asepticize  and  drain  any  existing 
wound ;  apply  iodin  to  the  inflamed  area  and  cover  it  with 
lint  wet  with  lead-water  and  laudanum,  and  if  a  limb  is  in- 
volved use  a  roller-bandage  and  a  sling.  Instead  of  iodin 
and  lead  water,  ichthyol  may  be  applied.  Open  the  bowels 
with  calomel  and  salines ;  order  quinin,  iron,  stimulants,  and 
nourishing  diet.  If  suppuration  occurs,  make  many  incisions 
near  together,  each  cut  being  2  or  3  inches  long.  Spray  out 
by  means  of  hydrogen  peroxid  in  an  atomizer,  and  then 
wash  with  corrosive-sublimate  solution  (i  :  looo).  Drain  by 
means  of  iodoform  gauze  in  strips.  Excise  spots  of  gan- 
grene. Dress  with  many  layers  of  gauze  wet  with  a  hot 
solution  of  corrosive  sublimate  and  covered  with  a  rubber- 
dam  ;  a  hot-water  bag  being  laid  upon  the  dressing.  If 
sloughs  form,  cut  them  partly  away  and  employ  antiseptic 
poultices.  Change  dressings  often.  Antistreptococcic  serum 
is  employed  by  some.  In  severe  cases  employ  hypodermo- 
clysis  or  saline  transfusion.  When  granulations  begin  to 
form,  treat  as  a  healing  wound. 

Cellulitis. — In  cellulitis  redness  of  the  skin  is  not  very 
pronounced  and  is  late  in  appearing,  following  swelling,  and 
not  preceding  it.  It  is  essentially  the  same  condition  as 
phlegmonous  erysipelas,  but  is  often  mild  in  degree.  Its 
spread  is  heralded  by  red  lines  of  lymphangitis  ascending 
from  an  infected  wound,  swelling  of  glands,  and  fever.  In 
slight  cases  the  lymphatics  may  dispose  of  the  poison  and 
suppuration  fail  to  occur.  In  severe  cases  septicemia  arises. 
Cellulitis  is  usually  a  result  of  infection  not  only  with  strep- 
tococci, but  also  with  other  pyogenic  cocci. 


144  MODERN  SURGERY. 

Treatment. — Incise  and  curet  the  wound  and  sear  it  with 
pure  carbolic  acid.  Treatment  is  the  same  as  for  the  phleg- 
monous form. 


XII.  TETANUS,  OR   LOCKJAW. 

Tetanus  is  an  infectious  spasmodic  disease  invariably  pre- 
ceded by  some  injury.  The  wound  may  have  been  severe, 
it  may  have  been  so  slight  as  to  have  attracted  no  attention, 
or  it  may  have  been  inflicted  upon  the  alimentary  canal  by  a 
fish-bone  or  other  foreign  body,  or  may  have  been  situated 
in  the  nose,  urethra,  vagina,  or  ear.  Idiopathic  tetanus  is 
either  not  tetanus  at  all,  or  is  a  term  expressive  of  the  fact 
that  we  have  not  found  an  injury  which  did  exist.  This  dis- 
ease is  commonest  after  punctured  or  lacerated'  wounds  of 
the  hands  or  feet,  and  before  it  appears  a  wound  is  apt  to 
suppurate  or  slough ;  but  in  some  instances  the  wound  is 
found  soundly  healed.  Tetanus  may  appear  twenty-four 
hours  after  an  accident,  but  it  may  not  arise  until  several 
weeks  have  elapsed.  It  prevails  more  in  certain  localities 
than  in  others.  Colored  people  are  very  susceptible,  and  it 
may  exist  epidemically.  Tetanus  is  due  to  infection  by  a 
bacillus  (first  described  by  Nicolaier  and  first  cultivated  by 
Kitasato),  the  toxic  products  of  which,  absorbed  from  the  in- 
fected area,  poison  the  nervous  system  precisely  as  would 
dosing  with  strychnin.  This  bacillus  is  found  particularly 
in  garden-soil,  in  the  dust  of  walls,  walks,  and  cellars,  in 
street-dirt,  and  in  the  refuse  of  stables. 

Symptoms. — Acute  tetanus  begins  within  nine  days  of 
an  accident.  The  usual  period  of  incubation  is  from  three 
to  five  days.  First,  the  neck  feels  stiff,  and  there  is  difficulty 
in  deglutition,  the  patient  thinking  he  has  taken  cold,  and 
next  the  jaws  also  become  stiff.  The  neck  becomes  like  an 
iron  bar,  and  the  jaws  as  rigid  as  steel.  The  muscles  of 
deglutition  become  rigid  on  attempts  at  swallowing.  The 
muscles  of  the  back,  legs,  and  abdomen  are  thrown  into 
tonic  spasm,  but  the  arms  rarely  suffer.  If  the  infected  in- 
jury is  on  the  hand  or  foot,  that  extremity  usually  is  found 
to  be  rigid.  Spasm  of  the  face-muscles  causes  the  risus  sar- 
doniens,  or  sardonic  smile  (contraction  particularly  of  the 
imiscidus  sardoiiicus  of  Santorini).  The  contraction  of  the 
muscles  of  the  back  is  often  so  powerful  as  to  bend  the  pa- 
tient back  like  a  bow  and  allow  him  to  rest  only  on  his  occi- 
put and  heels.  This  condition  is  known  as  "  opisthotonos." 
If  he  is  bent  forward,  so  that  the  face  is  drawn  to  the  legs,  it 


TETANUS,    OR  LOCKJAW.  1 45 

is  called  "  emprosthotonos."  If  his  body  is  curved  sideways, 
it  is  designated  "  pleurosthotonos."  An  upright  position  is 
"  orthotonos."  The  spasm  may  be  so  violent  as  to  cause 
muscular  rupture. 

The  state  is  one  of  widely  diffused  tonic  spasm,  aggravated 
frequently  by  clonic  spasms  arising  from  peripheral  irrita- 
tions. These  irritations  may  be  draughts,  sounds,  lights, 
shaking  of  the  bed,  attempts  at  swallowing,  contact  of  the 
bed-clothing,  the  presence  of  urine  in  the  bladder  or  of  feces 
in  the  rectum,  or  various  visceral  actions.  The  agonizing 
"  girdle-pain  "  so  often  met  with  is  from  spasm  of  the  dia- 
phragm. Each  clonic  spasm  causes  a  hideous  scream  by 
the  constriction  of  the  chest  forcing  air  through  a  contracted 
glottis.  Constipation  is  persistent ;  retention  of  urine  is  the 
rule  (because  of  sphincter  spasm).  The  mind  is  entirely 
clear  until  near  the  end — one  of  the  worst  elements  of  the 
disease.  Swallowing  in  many  cases  is  impossible.  Talking 
is  very  difficult  and  it  is  impossible  to  project  the  tongue. 
The  muscles  throughout  the  body  feel  very  sore.  The  tem- 
perature may  be  normal,  but  it  is  usually  a  little  elevated, 
and  always  rises  just  before  death.  Hyperpyrexia  some- 
times occurs  (io8°-iio°),  and  the  temperature  may  even 
ascend  for  a  time  after  death.  Insomnia  is  obstinate.  Death 
almost  invariably  occurs  in  acute  tetanus  in  two  or  three  days. 
It  may  be  due  to  exhaustion  or  to  carbonic-acid  narcosis  from 
spasm  of  the  glottis  or  fixation  of  the  respiratory  muscles. 

Chronic  tetanus  comes  on  late  after  a  wound  (from  ten 
days  to  several  weeks).  The  symptoms  are  not  so  severe ; 
the  muscular  spasm  is  widespread,  but  it  may  not  be  per- 
sistent, intervals  of  relaxation  permitting  sleep  and  the  taking 
of  food.  It  may  last  some  weeks,  and  not  infrequently  the 
disease  can  be  cured.  Trismus  is  a  mild  form  of  tetanus, 
the  contractions  being  limited  to  the  face  and  jaw.  Trismus 
neonatorum  or  trismus  nasccntium,  which  is  lockjaw  in  the 
newborn,  is  due  to  infection  of  the  stump  of  the  umbilical 
cord,  and  is  invariably  fatal.  Hydrophobic  tetanus,  head 
tetanus,  or  cephalic  tetanus,  is  a  condition  in  which  the 
spasms  are  confined  chiefly  to  the  face,  pharynx,  and  neck, 
although  the  abdominal  muscles  are  usually  also  rigid.  It 
follows  head-injuries,  and  gives  a  better  prognosis  than  does 
general  tetanus. 

Diagnosis. — Tetanus  may  be  confounded  with  strj'chnin- 
poisoning  or  with  hysteria.  Wood's  table  makes  the  diag- 
nosis clear  :  ^ 

^  A^en'oiis  Diseases,  by  Prof.  H.  C.  Wood. 
10 


146 


MODERN  SURGERY. 


Tetanus. 


Hysterical  Tetanus. 


Strychnin-poisoning. 


Muscular  symptoms 
usually  commence 
with  pain  and  stiffness 
in  the  back  of  the 
neck,  sometimes  with 
slight  muscular  twitch- 
ing ;  come  on  gradu- 
ally. Jaw  one  of  the 
earliest  parts  affected ; 
rigidly  and  persistent- 
ly set. 

Persistent  muscular 
rigidity  very  generally, 
with  a  greater  or  less 
degree  of  permanent 
opisthotonos,  empros- 
thotonos,  pleurosthot- 
onos,  or  orthotonos. 


Consciousness  pre- 
served until  near 
death,  as  in  strychnin- 
poisoning. 


Draughts,  loud 
noises,  etc.,  produce 
convulsions,  as  in 
strychnin  -  poisoning  ; 
may  complain  bitterly 
of  pain. 

Eyes  open  and  rig- 
idly fixed  during  the 
convulsion. 


Commences   with 
blindness  and  weakness. 


Muscular  symptoms 
commence  with  rigidity 
of  the  neck, which  creeps 
over  the  body,  affecting 
the  extremities  last.  Jaws 
rigidly  set  before  a  con- 
vulsion, and  remain  so 
between  the  paroxysms. 


Persistent  opisthoto- 
nos and  intense  rigidity 
between  the  convulsions 
and  after  the  convulsions 
have  ceased,  the  opis- 
thotonos and  intense  rig- 
idity lasting  for  hours. 


Consciousness  lost  as 
the  second  convulsion 
comes  on,  and  lost  with 
every  other  convulsion, 
the  disturbunce  of  con- 
sciousness and  motility 
being  simultaneous. 


Crying-spells  alterna- 
ting with  convulsions. 


Eyes  closed. 


Begins  with  exhilaration  and 
restlessness,  the  special  senses 
being  usually  much  sharpened. 
Dimness  of  vision  may  in  some 
cases  be  manifested  later,  after 
the  development  of  other  symp- 
toms, but  even  then  it  is  rare. 

Muscular  symptoms  develop 
very  rapidly,  commencing  in  the 
extremities,  or  the  convulsion 
when  the  dose  is  large  seizes 
the  whole  body  simultaneously. 
Jaw  the  last  part  of  the  body 
to  be  affected ;  its  muscles  re- 
lax first,  and  even  when,  during 
a  severe  convulsion,  it  is  set,  it 
drops  as  soon  as  the  latter  ceases. 

Muscular  relaxation  (rarely  a 
slight  rigidity)  between  the  con- 
vulsions, the  patient  being  ex- 
hausted and  sweating.  If  re- 
covery occurs,  the  convulsions 
gradually  cease,  leaving  merely 
muscular  soreness,  and  some- 
times stiffness  like  that  felt  after 
violent  exercise. 

Consciousness  always  pre- 
served during  convulsions,  ex- 
cept when  the  latter  become  so 
intense  that  death  is  imminent 
from  suffocation,  in  which  case 
sometimes  the  patient  becomes 
insensible  from  asphyxia,  which 
comes  on  during  the  latter  part 
of  a  convulsion  and  is  almost  a 
certain  precursor  of  death. 

The  "  slightest  breath  of  air" 
produces  convulsion.  Patient 
may  scream  with  pain  or  may 
express  great  apprehension,  but 
"crying-spells"  would  appear 
to  be  impossible. 

Eyes  stretched  wide  open. 


Partial  spasm  in  the        Legs   stiffly   extended   with 
leg,producing  in  Wood's  ^  feet  everted,  as  the  spasms  affect 


cases  crossing  of  the  feet 
and  inversion  of  the  toes. 
If  all  the  muscles  were 
involved, eversion  would 
occur,  as  the  muscles  of 
eversion  are  the  stronger. 


all  the  muscles  of  the  leg. 


TETANUS,    OR   LOCKJAW.  \\'J 

Treatment. — Far  better  than  even  to  treat  tetanus  well  is 
to  prevent  it.  Careful  antisepsis  will  banish  it  as  thoroughly 
as  it  has  banished  septicemia.  Every  wound  must  be  dis- 
infected with  the  most  scrupulous  care.  Every  punctured 
wound  is  to  be  incised  to  its  depth  and  thoroughly  cleaned 
and  drained.  Puerperal  tetanus  is  prevented  by  antiseptic 
midwifery,  and  tetanus  neonatorum  is  obviated  by  the  anti- 
septic treatment  of  the  stump  of  the  cord.  When  tetanus 
exists,  always  look  for  a  wound,  and  if  one  is  found,  open  it, 
cut  away  sloughs,  wash  with  peroxid  of  hydrogen  and  cor- 
rosive sublimate,  swab  it  out  with  bromin,  and  secure  drain- 
age by  packing  it  with  iodoform  gauze. 

Isolate  the  patient,  as  the  disease  is  infective ;  keep  him 
in  a  darkened,  well-ventilated,  and  quiet  apartment,  so  as  to 
exclude  as  far  as  possible  peripheral  irritation.  Watch 
for  retention  of  urine,  and  use  the  catheter  if  it  occurs. 
Secure  movements  of  the  bowels  by  salines,  castor  oil,  croton 
oil,  or  enemas.  Give  plenty  of  concentrated  liquid  food,  and 
stimulate  freely  with  alcohol.  If  swallowing  causes  convul- 
sions, give  an  inhalation  of  nitrite  of  amyl  before  an  attempt 
is  made  to  swallow.  If  this  treatment  fails,  partially  anes- 
thetize the  patient  and  feed  him  by  means  of  a  pharyngeal 
tube  passed  through  the  nose.  Large  doses  of  the  bromid 
of  potassium,  or  of  this  drug  with  chloral,  give  the  best  re- 
sults. If  bromid  is  used,  give  about  3j  every  four  to  six 
hours.  Other  drugs  that  have  been  used  with  some  success 
are  gelsemium,  morphin,  curare,  injections  and  fomentations 
of  tobacco,  physostigmin,  anesthetics,  cocain,  and  cannabis 
indica.  An  ice-bag  to  the  spine  somewhat  relieves  the 
girdle-pain.     Hot  baths  have  been  advdsed. 

Yandell  says,  in  summing  up  Cowling's  report  on  tetanus  •} 
"  Recoveries  from  traumatic  tetanus  have  been  usually  in 
cases  in  which  the  disease  occurs  subsequent  to  nine  days 
after  the  injury.  When  the  symptoms  last  fourteen  days, 
recovery  is  the  rule,  apparently  independent  of  treatment. 
The  true  test  of  a  remedy  is  its  influence  on  the  history  of 
the  disease.  Does  it  cure  cases  in  which  the  disease  has  set 
in  previous  to  the  ninth  day  ?  Does  it  fail  in  cases  whose 
duration  exceeds  fourteen  days  ?  No  agent  tried  by  these 
tests  has  yet  established  its  claims  as  a  true  remedy  for 
tetanus."  ^ 

It  is  now  claimed  by  some  observers  that  we  have  a  rem- 
edy which  fulfils  the  requirements  of  Yandell  in  the  tetanus 

1  American  Practitioner,  Sept.,  1870. 

^  Quoted  by  Hammond,  in  his  Diseases  of  the  Nervous  System. 


148 


MODERN  SURGERY. 


antitoxin  of  Tizzoni  and  Cattani.  To  prepare  this  antitoxin 
a  horse  is  rendered  immune  to  tetanus  by  inoculations  with 
mitigated  cultivations  of  the  microbe  ;  stronger  and  stronger 
cultures  are  given ;  the  blood  is  drawn,  and  the  serum  is 
separated  and  treated  with  alcohol  and  dried  in  a  vacuum. 
The  antitoxin  is  dissolved  in  glycerin,  and  is  used  hypo- 
dermatically  in  doses  of  from  15  to  25  centigrammes.  Some 
physicians  have  injected  the  serum  itself  Cures  seem  to 
have  followed  its  use,  and  if  it  can  be  obtained  it  is  our  duty 
to  try  it  in  acute  tetanus.  Kitasato  has  shown  that  injec- 
tions of  iodoform  render  animals  immune,  and  Sonnani  has 
maintained  that  this  drug  in  a  wound  prevents  the  disease. 
If  antitoxin  is  not  obtainable,  give  hypodermatic  injections 
of  iodoform  3  to  5  grs.  /.  /.  d. 


XIII.  TUBERCULOSIS. 

Tuberculosis  is  an  infective  disease  due  to  the  deposition 
and  multiplication  of  the  bacilli  of  tubercle  in  the  tissues 
of  the  body.  It  is  characterized  either  by  the  formation  of 
tubercles  or  by  a  widespread  infiltration,  both  of  these  con- 
ditions tending  to  caseation,  sclerosis,  or  ulceration.  A 
tubercular  lesion  may  undergo  calcification. 

A  tubercle  is  an  infective  granuloma,  appearing  to  the 
unaided  vision  as  a  semitransparent  gray  mass  the  size 
of  a   mustard-seed.     The   microscope    shows   that   a    gray 

tubercle  consists  of  a  number  of 
cell-clusters,  each  cluster  constitut- 
ing a  primitive  tubercle.  A  typi- 
cal primitive  tubercle  shows  a  cen- 
ter consisting  of  one  or  of  several 
polynucleated  giant-cells  surround- 
ed by  a  zone  of  epithelioid  cells 
which  are  surrounded  by  an  area 
of  leukocytes.  When  the  bacillus 
obtains  a  lodgement  the  fixed  con- 
nective-tissue cells  multiply  by  kary- 
okinesis,  forming  a  mass  of  nucle- 
ated polygonal  or  round  cells,  called 
"  epithelioid  "  from  their  resemblance 
to  epithelial  cells,  and  at  the  same 
time  the  blood-supply  of  the  growth 
is  limited  by  occlusion  of  surround- 
ing vessels  through  multiplication 
of  their  endothelial  coats.     Some   of  these  epithehoid  cells 


•  r^:i^»» 


Fig.    37. — Synovial    membrane, 
showirtg  giant-cells  (Bowlby). 


TUBE  R  CUL  OSIS.  1 49 

proliferate,  and  others  attempt  to,  but  fail  for  want  of  blood- 
supply.  Those  that  fail  succeed  only  in  dividing  their 
nuclei  and  enormously  increasing  their  bulk  (giant-cells). 
Giant-cells,  which  also  form  by  a  coalescence  of  epithelioid 
cells,  are  not  always  present.  The  presence  of  irritant  bac- 
terial products  induces  surrounding  inflammation  and  exuda- 
tion of  white  blood-cells  (Fig.  37). 

The  bacillus,  when  found,  exists  in  the  epithelioid  cells,  and 
sometimes  in  the  giant-cells  ;  it  may  not  be  found,  having  once 
existed,  but  having  been  subsequently  destroyed.  It  is  often 
overlooked.  In  an  active  tubercular  lesion,  even  if  the  bacil- 
lus be  not  found,  injection  of  the  matter  into  a  guinea-pig 
will  produce  lesions  in  which  it  can  be  demonstrated.  A 
tubercle  may  caseate — a  process  that  is  destructive  and  dan- 
gerous to  the  organism.  Caseation  is  due  to  a  coagulation- 
necrosis  arising  from  direct  microbic  action  upon  a  cellular 
area  w^hich  contains  no  blood-vessels,  the  nutrition  of  the 
area  being  cut  off  by  obliteration  of  surrounding  vessels. 
This  process  starts  at  the  center,  and  the  entire  tubercle 
becomes  converted  into  a  soft  yellowish-gray  mass.  Case- 
ation forms  cheesy  masses,  which  may  soften  into  tubercu- 
lar pus,  may  calcify,  and  may  become  encapsuled  by  fibroid 
tissue. 

A  tubercle  may  undergo  sclerosis,  which  is  an  attempt  on 
the  part  of  Nature  to  heal  and  repair.  Coagulation-necrosis 
occurs  in  the  centre  of  the  tubercle  ;  "  hyaline  transformation 
proceeds,  together  with  a  great  increase  in  the  fibroid  ele- 
ments, so  that  the  tubercle  is  converted  into  a  firm,  hard 
structure  "  (Osier).  Infiltrated  tubercle  is  due  to  the  running 
together  of  many  minute  infective  foci,  or  to  widespread  in- 
filtration without  any  formation  of  foci.  Infiltrated  tubercle 
tends  strongly  to  caseate. 

The  bacillus  of  tubercle,  discovered  by  Koch,  is  a  little 
rod  with  a  length  equal  to  about  half  the  diameter  of  a  red 
blood-corpuscle.  It  can  be  stained  with  anilin,  and  this  stain 
is  not  removable  by  acids  (it  being  the  only  bacillus  except 
leprosy  which  acts  in  this  way).  In  its  growth  the  tubercle 
bacillus  causes  the  formation  of  toxins,  and  the  absorption 
of  toxins  induces  constitutional  symptoms.  These  bacilli 
exist  in  all  active  lesions :  the  more  active  the  process  the 
greater  is  their  number.  They  may  be  widely  distributed, 
and  are  occasionally  though  rarely  identified  in  the  blood. 
They  exist  in  enormous  numbers  in  phthisical  sputum,  but 
are  not  found  in  the  breath  of  consumptives.  Their  great 
medium  of  distribution  is  dried  sputum  mixed  with  dust. 


150  MODERN  SURGERY. 

They  are  found  in  the  milk  of  tubercular  cows,  and  some- 
times in  the  meat  of  diseased  animals. 

Infection  may  be  due  to  hereditary  transmission.  Con- 
genital tuberculosis  is  occasionally,  though  rarely,  seen. 
Tuberculosis  is  apt  to  appear  in  young  children.  Some 
think  this  is  due  to  infection  from  without  upon  tissues 
whose  resistance  is  lowered  by  hereditary  predisposition ; 
others  think  it  is  due  to  a  tardy  development  of  the  germs 
transmitted  by  heredity.  That  the  disease  may  be  present 
in  a  latent  form  is  shown  by  the  experiment  in  which  the 
viscera  of  the  fetus  of  a  consumptive  mother  showed  no 
tubercles,  but  produced  the  disease  in  guinea-pigs  when 
inoculated.^  Tuberculosis  may  arise  by  inoculation,  inocu- 
lation-tuberculosis being  seen  in  leather- workers  and  in  those 
who  dissect  tubercular  bodies  (butchers  and  doctors  are 
liable  to  anatomical  tubercle).  Osier  mentions  as  other  causes 
of  inoculation  the  bite  of  a  tubercular  patient,  the  washing 
of  infected  garments,  and  circumcision  in  which  suction  is 
employed  by  an  individual  with  phthisis.  Granulation-tissue, 
chronic  abscess,  and  areas  of  dermatitis  may  be  infected  from 
without  (G.  R.  Fowler).  Infection  through  the  air  is  very 
common.  The  bacteria  of  the  dried  sputum  adhere  to  par- 
ticles of  dust  and  are  carried  into  the  lungs.  Infection  by 
meat,  milk,  and  other  foods  may  arise  by  this  dust  settHng 
upon  them  in  quantity.  Commonly,  however,  it  is  due  to 
disease  of  the  animals.  Milk  is  a  common  vehicle  of  con- 
tagion, and  it  can  be  infected  even  when  an  ulcerated  udder 
does  not  exist. 

Infection  is  favored  by  hereditary  predisposition — that  is 
to  say,  by  hereditary  tissue-weakness,  which,  by  maintaining 
a  lowered  momentum  of  nutritive  processes,  lessens  the  nor- 
mal resistance  to  infection.  Hutley  studied  432  cases  of 
tuberculosis.  In  23.8  per  cent,  one  or  both  parents  had  the 
disease  (the  father  alone  in  11.5  per  cent,  the  mother  alone 
in  9.9.  per  cent,  and  both  in  2.4  per  cent).  Two  types  of 
these  predisposed  persons  are  mentioned :  (i)  the  sanguine  - 
type,  or  those  with  oval  faces,  clear  skin,  large  blue  eyes, 
long  lashes,  a  nervous  manner,  precocious  minds,  but  little 
fat,  and  with  long,  slender  bones,  these  children  being  often 
graceful  and  beautiful ;  and  (2)  those  with  stolid  counte- 
nances, thick  lips  and  noses,  thick,  muddy  skin,  dark,  coarse 
hair,  swollen  necks,  heavy  bones,  clumsy  gait,  and  ungainly 
figure.  The  latter  type  is  the  phlegmatic  form — the  classical 
scrofula. 

^  Quoted  by  Osier  from  Birch-Hirschfeld. 


TUBERCUL  OSIS.  1 5 1 

There  is  no  doubt  that  an  inflammatory  area  in  a  person 
ma\'  become  infected  when  a  sound  area  would  escape,  the 
process  of  phagocytosis  being  in  this  spot  Hmited  in  activity, 
and  the  germicidal  power  of  the  body-fluids  being  at  a  low 
ebb.  The  organisms,  which  are  destroyed  by  healthy  cell- 
activities,  are  victorious  when  those  activities  are  diminished. 
Catarrhal  inflammations  of  the  air-passages  favor  phthisis, 
and  traumatism  is  not  unusually  followed  by  a  development 
of  tubercle.  Lowered  health,  impure  air,  and  improper  or 
insufficient  food  all  favor  the  development  of  tubercle.  Any 
tubercular  process  tends  to  spread  locally  and  to  produce 
inflammation.  A  tubercular  area  is  always  a  danger  to  the 
system  ;  from  this  as  a  focus  dissemination  may  occur,  tuber- 
cular lesions  appearing  in  a  distant  part  or  general  tubercu- 
losis setting  in. 

Scrofula  is  not  a  disease.  It  is  a  condition  of  tissues  in 
which  low  resisting  power  makes  them  hospitable  hosts  to  in- 
vading bacilli  of  tubercle.  Some  observers  teach  that  scrofula 
is  tuberculosis  of  bones,  glands,  and  joints  ;  others  teach  that 
it  is  latent  tuberculosis  until  some  cause  lights  it  into  activity; 
while  still  others  say  that  it  is  a  tendency  rather  than  a  dis- 
ease. It  is  certain  that  some  lesions  of  scrofula  are  not  tu- 
bercular (eczema  capitis,  facial  eczema,  corneal  ulcers,  gran- 
ular lids,  and  chronic  catarrhal  inflammations),  and  that  they 
result  from  ill-health,  poor  nutrition,  bad  air,  and  improper 
diet.  A  person  who  is  recognized  as  of  a  scrofulous  type 
may  nev^er  develop  tubercular  lesions.  It  is  unquestionable, 
however,  that  strumous  subjects  are  peculiarly  apt  to  develop 
true  tubercular  lesions.  These  lesions  often  appear  after  a 
tissue  or  an  organ  has  become  the  seat  of  a  primary  non-tu- 
bercular inflammation  ;  the  bacilli,  which  could  not  live  in  the 
non-inflamed  tissue,  thriv-e  in  the  inflamed  tissue.  Scrofula  is 
generally  of  congenital  origin,  one  or  both  parents  being  tu- 
bercular, scrofulous,  or  in  ill-health  ;  it  may,  however,  be 
acquired  as  a  result  of  poor  food,  bad  air,  crowding,  and  gen- 
eral lack  of  sanitation.  The  scrofulous  are  very  prone  to 
develop  tubercular  lesions  of  bones,  joints,  and  lymphatic 
glands.  When  tubercular  processes  arise  the  urine  is  some- 
times found  to  contain  indican. 

Tubercular  Abscess. — For  description  of  tubercular 
abscess,  see  p.  105. 

Tuberculosis  of  the  Skin. — Lupus  begins  before  the 
age  of  twenty-five,  most  usually  upon  the  face,  especially 
the  nose.  Three  forms  are  recognized:  {i)  lupus  vulgaris y 
in  which  pink  nodules  appear  that  after  a  time  ulcerate  and 


I  5  2  MODERN  SURGE R  V. 

then  cicatrize.  These  nodules  resemble  jelly  in  appearance; 
(2)  liipiis  exedciis,  in  which  ulceration  is  very  great ;  and  (3) 
liLpiis  hypei'tropJiiciis,  in  which  a  very  great  amount  of  em- 
bryonic tissue  is  produced  (large  nodules  or  tubercles).  Lupus 
may  appear  as  a  pimple,  as  a  group  of  pimples,  Or  as  nodules 
of  a  larger  size.  The  ulcer  arises  from  desquamation,  and  is 
surrounded  by  inflammatory  products  which,  by  progres- 
sively'breaking  down,  add  to  its  size.  The  ulcer  is  usually 
superficial,  is  irregular  in  outline,  the  edges  are  soft  and 
neither  sharp  nor  undermined,  the  sore  gives  origin  to  a  small 
amount  of  thin  discharge,  the  parts  about  are  of  a  yellow-red 
color,  and  there  is  no  pain,  the  edges  are  solid  and  puckered 
and  scar-like.  The  ulcer  is  often  crusted  over,  the  crusts 
being  thin  and  of  a  brown  or  black  color ;  it  may  be  pro- 
gressing at  one  point  and  healing  at  another ;  and  it  is  slow 
in  advancing,  but  often  proves  hideously  destructive.  The 
scars  left  by  its  healing  are  firm  and  corrugated,  but  are  apt 
to  break  down.  Clinically  it  is  separated  from  a  rodent  ulcer 
by  several  points.  The  rodent  ulcer  is  deep,  its  edges  are 
everted,  and  the  parts  about  filled  with  visible  vessels.  It  is 
not  crusted,  has  not  a  puckered  edge,  does  not  spontane- 
ously heal  at  any  point,  and  its  edges  and  base  are  hard. 

Anatomical  tubercle,  the  verruca  necrogenka  of  Wilks, 
is  due  to  local  inoculation  with  tubercular  matter.  It  is  seen 
in  surgeons,  the  makers  of  post-mortems,  leather-workers, 
and  butchers,  usually  upon  the  backs  of  the  hands  and  fin- 
gers. It  consists  of  a  red  mass  of  granulation-tissue  having 
the  appearance  of  a  group  of  inflamed  warts.  Pustules  often 
form. 

Scrofulodermata  or  tubercular  gummata  are  chronic 
skin-inflammations,  the  granulation-tissue  product  of  which 
breaks  down  to  form  small  abscesses,  sinuses,  or  ulcers.  A 
tubercular  ulcer  has  a  floor  of  a  pale  color,  and  has  no  gran- 
ulations at  all,  or  is  covered  with  edematous  granulations. 
The  discharge  is  thin  and  scanty.  It  is  surrounded  by  a  con- 
siderable zone  of  purple,  tender,  and  undermined  skin,  which 
is  apt  to  slough.  When  heaHng  occurs  the  skin  puckers  and 
inverts. 

Tuberculosis  of  Subcutaneous  Connective  Tissue. 
— In  this  form  of  tuberculosis  nodules  of  granulation-tissue 
form  and  break  down  (tubercular  abscesses).  In  the  deeper 
tissues  these  abscesses  are  usually  associated  with  bone-, 
joint-,  or  lymphatic-gland  disease.  A  large  abscess  is  called 
"  cold "  (see  Cold  Abscess,  p.  105).  Tuberculosis  of  the 
mammary  gland  is  rare,  but  occasionally  occurs  (p.  108). 


TUBERCUL  OSIS.  I  5  3 

Pulmonary  Tuberculosis. — In  adults  the  lungs  are 
more  commonly  affected  than  any  other  structure.  The 
lung  affection  may  be  primary  or  may  be  secondary  to  some 
distant  process  of  tubercular  disease.  Pulmonary  tubercu- 
losis belongs  to  the  physician  and  requires  no  description 
here. 

Tuberculosis  of  the  Alimentary  Canal. — A  tuber- 
cular ulcer  of  the  lip  occasionally  occurs,  and  is  usually  mis- 
taken for  a  cancer  or  a  chancre.  A  tubercular  ulcer  of  the 
tongue  is  commonly  associated  with  other  foci  of  disease. 
Such  ulcers  are  separated  from  cancer  by  their  soft  bases 
and  edges  and  by  the  absence  of  glandular  enlargements, 
and  from  syphilitic  processes  by  the  therapeutic  test.  Con- 
firmation of  the  diagnosis  is  obtained  by  cultiv^ations  and  in- 
oculations. Tubercle  may  affect  the  pharynx,  palate,  tonsils, 
and  very  rarely  the  stomach. 

Intestinal  tuberculosis  may  follow  pulmonary  tubercle, 
but  it  may  arise  primarily  in  the  mucous  membrane  of  the 
bowel  or  result  from  tubercular  peritonitis.  Intestinal  tu- 
berculosis causes  diarrhea  and  fever,  may  resemble  appendi- 
citis, and  may  cause  abscess  and  perforation.  Fistula  in  ano 
is  very  often  tubercular,  and  when  it  is  the  lungs  are  very 
often  involved,  the  pulmonary  lesion  being  primary. 

Tuberculosis  of  the  liver  causes  cold  abscess  and  cirrhosis. 
Tubercle  may  affect  the  kidneys,  bladder,  ureters.  Fallopian 
tubes,  prostate,  urethra,  seminal  vesicles,  ovaries,  and  uterus. 
Tubercular  testicle  is  not  rare.  It  is  rarely  primary,  being, 
as  a  rule,  preceded  by  tuberculosis  of  the  kidney,  bladder,  or 
prostate.  Tubercular  orchitis  affects  one  testicle  at  first,  but 
the  other  usually  becomes  involved.  It  starts  in  the  epidid- 
ymis as  a  painless  nodule.  As  the  vaginal  tunic  and  testicle 
become  involved  a  hydrocele  forms.  The  tubercular  mass 
softens,  becomes  adherent  to  the  scrotum,  and  bursts.  The 
cord  is  always  more  or  less  involved. 

Peritoneal  tuberculosis  may  be  primary,  infection  hav- 
ing been  by  way  of  the  blood,  may  be  part  of  a  diffused 
process,  or  may  follow  intestinal  tubercle,  the  serous  and 
muscular  coats  of  the  bowel  having  been  at  some  point  in 
contact  or  a  follicular  ulcer  having  perforated  (Abbe).  The 
germ  may  have  entered  by  the  Fallopian  tube.  It  may  be 
due  to  ovarian  or  Fallopian  tuberculosis,  or  to  ulceration 
of  a  tubercular  appendix.  It  causes  usually  ascites,  tym- 
pany, and  tumor-like  formations  composed  of  adherent 
bunches  of  bowel  or  omentum  or  distended  mesenteric 
glands  (p.  657). 


154  MODERN  SURGERY. 

The  pericardium  may  be  attacked  with  tuberculosis  pri- 
marily or  secondarily  to  pleural  tuberculosis.  The  pleura 
is  not  uncommonly  attacked.  Tubercular  pleurisy  may  be 
acute  or  chronic.  In  some  instances  mixed  infection  takes 
place  and  suppuration  occurs.  The  tuberculosis  may  be 
primary,  but  is  usually  secondary  to  pulmonary  tuberculosis, 
and  may  be  due  to  direct  extension  or  to  the  rupture  of  an 
area  of  pulmonary  softening. 

Tuberculosis  of  the  brain  induces  meningitis  and 
hydrocephalus  (p.  559). 

Tubercular  disease  of  bone  is  very  common  in  youth  ; 
is  usually  preceded  by  a  sprain  or  a  contusion,  slight  or  se- 
vere. The  injury  establishes  a  point  of  least  resistance,  and 
in  the  damaged  area  the  bacilli  are  deposited  and  multiply. 
The  organisms  may  be  deposited  directly  from  the  blood,  or 
may  come  in  an  embolism  from  a  distant  tubercular  focus 
(lung  or  lymph-gland),  which  embolus  is  caught  in  a  termi- 
nal artery  in  the  end  of  a  long  bone  and  causes  a  wedge- 
shaped  infarction  (Warren). 

Tubercular  osteitis,  as  a  rule,  begins  just  beneath  the 
articular  cartilage  or  in  the  epiphysis  (Warren).  The  prod- 
ucts of  the  tubercular  inflammation  may  be  absorbed,  may 
be  encapsuled  by  fibrous  tissue,  or  may  caseate. 

Tubercular  disease  of  the  joints  is  called  "white 
swelling "  and  pulpy  degeneration  of  the  synovial  mem- 
brane. Joints  are  especially  liable  to  tuberculosis  in  youth, 
although  the  wrist  and  shoulder  not  infrequently  suffer  in 
adult  life.  Joint-tuberculosis  is  often  preceded  by  an  injury. 
The  tubercular  process  may  begin  in  the  synovial  membrane, 
especially  in  the  knee,  but  it  usually  starts  in  the  head  of  a 
bone,  dry  caries  resulting,  necrosis  ensuing,  or  an  abscess 
forming  which  breaks  into  the  joint  (p.  408). 

Tuberculosis  of  lymphatic  glands  is  known  as  "  tu- 
bercular adenitis."  It  is  the  most  typical  lesion  of  scrofula. 
The  common  antecedent  of  a  tubercular  adenitis  of  the  neck 
is  slight  glandular  enlargement  as  a  result  of  catarrhal  inflam- 
mation of  the  mucous  membrane  of  the  mouth.  It  is  most  fre- 
quent between  the  third  and  fifteenth  years.  A  person  not  of 
the  tubercular  type  may  acquire  tuberculosis  of  the  glands, 
but  adenitis  is  unquestionably  of  much  greater  frequency  in 
the  tubercular.  Tubercular  glands  may  get  well,  may  even 
calcify,  but  usually  caseate  if  left  alone.  After  healing  they 
may  break  down  and  soften  (residual  abscess).  They  very 
frequently  suppurate  because  of  mixed  infection.  Though 
at  first  a  local  disease,  inflamed  glands  may  prove  to  be  foci 


TUBERCUL  OS  IS.  1 5  5 

of  infection,  infecting  distant  organs  or  the  entire  system. 
Glandular  enlargement  is  in  rare  instances  widely  diffused, 
but  it  is  far  more  commonly  localized.  Enlargement  of  the 
cervical  glands  is  most  common.  Enlargement  of  the  mesen- 
teric glands  causes  tabes  mesenterica. 

Cervical  lymphadenitis  may  be  confused  with  lymphade- 
noma.  The  former,  as  a  rule,  first  appears  in  the  submaxil- 
lary triangle,  the  latter  in  the  occipital  or  inferior  carotid  tri- 
angles. Tubercular  glands  weld  together,  they  are  apt  to 
remain  localized,  and  they  tend  to  soften.  They  may  be  ac- 
companied by  other  tubercular  manifestations.  Lymphade- 
noma  from  the  start  affects  many  glands  in  several  regions, 
shows  no  tendency  to  suppurate,  and  is  accompanied  by  great 
debility  and  anemia.  Malignant  gland-tumors  infiltrate  adja- 
cent glands  and  other  structures,  binding  skin,  muscles,  and 
glands  into  one  hard  firm  mass. 

Diagnosis. — The  diagnosis  may  be  determined  by  purely 
clinical  facts.  It  may  require  the  use  of  the  microscope, 
cultivation-experiments,  or  inoculations.  In  a  suspected 
tubercular  lesion  remove  a  portion  of  the  tissue  if  it  be 
accessible  (by  Mixter's  cannula)  and  make  sections,  stains, 
and  cultivations.  If  no  bacilli  are  found,  inoculate  a  guinea- 
pig  with  the  suspected  material.  If  it  be  tubercular,  the  pig 
will  develop  miliary  tuberculosis  in  a  few  weeks. 

Prognosis. — The  prognosis  varies  with  age,  sex,  duration, 
extent,  and  situation  of  the  lesion.  Prognosis  is  best  in  chil- 
dren, and  is  better  in  males  than  in  females.  Tuberculosis 
of  the  skin  gives  a  fair  prognosis.  Tubercular  adenitis  is 
often  cured.  Any  tubercular  lesion  is,  however,  a  menace  to 
the  organism,  and  tends  strongly  to  recurrence. 

Treatment. — Destroy  the  bacilli  present  and  radically  re- 
move infected  areas  which  are  accessible.  Never  remove  only 
part  of  a  focus.  Incomplete  operations  are  apt  to  be  fol- 
lowed by  diffuse  tuberculosis.  Among  the  many  drugs 
which  have  been  recommended  for  local  use  we  mention 
the  following :  iodin,  carbolic  acid,  guaiacol,  arsenous  acid, 
corrosive  sublimate,  chlorid  of  zinc  (Lannelongue),  phosphate 
of  iron,  balsam  of  Peru  (Landerer),  camphorated  naphtol, 
oil  of  cinnamon,  cinnamic  acid  (Landerer),  and  iodoform.^ 
Iodoform  used  locally  upon  or  in  tubercular  areas  is  of 
great  value,  and  there  is  no  drug  which  takes  its  place. 
Lupus  may  be  treated  by  the  application  of  blue  oint- 
ment ;    by    curetting,   cauterizing    with    carbolic    acid,    and 

^  See  article  upon  "Tuberculosis"  by  George  Ryerson  Fowler,  Brooklyn 
Med.  Jour.,  Nos.  8  and  9,   1894. 


156  MODERN  SURGERY. 

dressing  with  iodoform ;  by  excision,  followed  in  some 
instances  by  sliding  in  of  a  flap  of  sound  tissue  or  im- 
mediate skin-grafting.  If  we  are  treating  a  nodular  and 
non-ulcerated  area,  wash  it  with  a  2  per  cent,  solution  of  cor- 
rosive sublimate  and  inject  several  nodules  with  camphorated 
naphtol,  one  drop  for  each  nodule.  In  seven  or  eight  days 
inject  other  nodules,  and  so  on.  Koch's  lymph  has  cured 
some  cases  of  lupus.  Tubercular  glands  before  breaking 
down  should  be  rubbed  with  ichthyol,  and  if  this  fails  to  cure 
they  should  be  removed.  When  they  break  down  they 
should  be  removed  or  opened,  curetted,  and  packed.  The 
rule  must  be  to  completely  dissect  out  enlarged  lymphatic 
glands  which  fail  to  quickly  respond  to  treatment,  removing 
capsules  and  glands.  Climate  is  of  very  great  importance. 
Osier  sums  up  climatic  necessities  as  "  pure  atmosphere, 
equable  temperature,  and  maximum  amount  of  sunshine." 
Open-air  life  is  imperative.  The  patient  must  have  a  well- 
ventilated  sleeping-room,  and  his  house  should  be  free  from 
dampness.  Nourishing  diet  is  essential.  To  gain  in  weight 
is  a  constant  aim.  Give  meat,  milk,  cream,  butter,  and  cod- 
liver  oil,  which  may  be  administered  in  capsules.  The  oil  is 
poorly  borne  in  hot  weather,  during  which  it  should  be  dis- 
continued. Advancing  doses  of  creasote,  arsenic,  quinin,  and 
stimulants  have  their  uses.  (For  treatment  of  tuberculosis  of 
bones,  joints,  peritoneum,  pleura,  etc.,  look  under  special  re- 
gional headings.) 

Bier's  Method. — A  few  years  ago  Bier  set  forth  a  new 
plan  for  treating  tubercular  lesions.  It  consists  in  causing 
venous  obstruction  and  passive  congestion.  In  the  area  of 
passive  congestion  the  tissue-cells  form  antitoxins  which 
kill  the  bacteria  or  attenuate  their  virulence.  The  treatment 
is  founded  upon  the  principle  announced  by  Laennec,  that 
"  cyanosis  is  antagonistic  to  tubercle."  The  plan  is  applied 
particularly  in  joint-tuberculosis.  An  elastic  band  three 
inches  broad  is  placed  around  the  limb,  above  the  seat  of 
disease,  and  it  is  applied  sufficiently  tightly  to  cause  conges- 
tion. Several  pieces  of  lint  ought  to  be  interposed  between 
the  skin  and  the  band.  By  applying  a  flannel  bandage 
from  the  periphery  to  the  lower  border  of  the  disease  the 
congestion  is  limited  to  the  area  of  trouble.  The  patient 
should  wear  the  band  continually  and  move  about  with  it 
on.  Some  people  wear  it  without  any  inconvenience,  but 
others  complain  greatly  after  wearing  it  but  a  short  time. 
Bier  and  others  have  reported  cures.  We  have  seen  great 
mitigation  of  pain  and  temporary  arrest  in  the  advance  of 


TUBEK  CUL  OSIS.  1 5  7 

the  malady,  but  have  never  seen  a  cure  brought  about  by 
the  method. 

Koch's  T2ibcrc2(li)t. — The  specific  treatment  by  Koch's  tu- 
bercuHn  or  paratoloid  has  excited  widespread  interest.  It 
has  not  fulfilled  the  expectations  which  many  entertained, 
but  does  benefit  some  cases,  notably  lupus.  A  serious  draw- 
back to  the  value  of  Koch's  tuberculin  is  that  it  often  causes 
fever  and  inflammation  to  a  dangerous  degree.  In  some 
cases,  as  Virchow  showed,  it  produces  acute  miliary  tubercu- 
losis. Koch's  lymph  is  a  glycerin-extract  of  a  culture  of 
tubercle  bacilli,  and  the  usual  dose  is  i  milligram,  given  hy- 
podermatically  into  the  back  by  Koch's  pistonless  syringe. 
After  it  has  been  used  for  a  time  the  dose  may  be  increased 
to  10  milligrams,  or  even  much  more.  Bergmann  gave  i 
gram.  Koch's  lymph  causes  inflammation  and  necrosis  of 
tubercular  tissue  by  the  action  of  certain  antitoxins.  Many 
cases  it  improves.  Some  cases  it  apparently  cures,  but  the 
disease  is  apt  to  return.  In  pulmonary  tubercle  it  must  not 
be  given  if  there  be  much  fever  or  extensive  consolidation. 
Chiene  used  tuberculin  largely  in  joint-cases  by  giving  two 
or  three  doses  a  day  and  increasing  the  dose.  It  is  best  to 
associate  other  treatment  with  the  lymph.  Tuberculin  may 
be  used  for  diagnostic  purposes  in  animals.  If  tuberculosis 
exists,  an  injection  of  tuberculin  produces  a  marked  reaction. 
Czerny  has  shown  that  in  renal  tuberculosis  in  a  human 
being  bacilli  are  often  absent  from  urine,  but  an  injection  of 
tuberculin  will  cause  bacilli  to  appear  plentifully.  Koch  has 
recently  modified  his  tuberculin.  He  makes  it  as  follows  : 
dried  cultures  of  bacilli  are  mixed  with  distilled  water,  and 
the  mixture  is  agitated  in  a  centrifuge.  Two  layers  separate. 
The  upper  layer  is  the  old  tuberculin.  The  lower  layer  is 
the  new  tuberculin.  The  new  tuberculin  is  given  hypoderm- 
atically,  at  first  in  very  small  doses,  but  finally  in  doses  as 
large  as  20  milligrams.  It  is  not  to  be  given  to  far  advanced 
cases  or  cases  with  much  fever. 

Hunter,  of  London,  declares  that  Koch's  lymph  contains 
one  principle  which  causes  fever,  another  which  causes  in- 
flammation, and  a  third  which  produces  atrophy  of  tuber- 
cular foci  without  either  fever  or  inflammation.  This  third 
desirable  element  he  believes  he  has  isolated  in  what  is 
called  a  "  derivative  of  tuberculin,"  a  modified  lymph.  Some 
remarkable  results  have  followed  the  use  of  this  material ; 
its  administration  seems  entirely  safe,  and  it  should  thor- 
oughly and  carefully  be  tried  to  ascertain  its  true  rank  as  a 
remedy.     The  injection  of  serum  obtained  from  animals  re- 


158  MODERN  SURGERY. 

fractory  to  tubercle  has  been  employed,  but  Richet  and 
Hericourt  have  seen  no  benefit  from  the  plan.  Maragliano, 
of  Genoa,  uses  a  serum  which  he  believes  can  cure  tubercu- 
losis. He  immunizes  animals  not  by  injection  of  living  cul- 
tures, but  by  employing  the  toxic  principles  extracted  from 
them.  Progressive  vaccinations  immunize  a  dog.  The  serum 
of  the  animal  is  injected  for  the  cure  of  tuberculosis  in  man 
or  other  animals.  If  injected  with  tuberculin,  it  neutralizes 
the  general  and  local  reaction  of  the  latter  agent.  The  serum 
has  apparently  benefited  many  cases,  but  is  useless  against 
mixed  infections.^ 

XIV.  RICKETS. 

Rickets  is  a  constitutional  disease  arising  during  the 
early  years  of  life  (the  first  two  or  three)  as  a  result  of 
insufficient  or  of  improper  diet  and  bad  hygienic  surround- 
ings. A  deficiency  of  fat  and  phosphate  in  the  food  or  the 
use  of  a  diet  which,  by  inducing  gastro-intestinal  catarrh, 
prevents  assimilation,  causes  rickets.  The  disease  is  never 
congenital,  the  so-called  "  congenital  rickets  "  being  sporadic 
cretinism  (Bowlby). 

Evidences  of  Rickets. — The  condition  is  one  of  gen- 
eral ill-health ;  the  child  is  ill-nourished,  pallid,  flabby ;  it 
has  attacks  of  diarrhea  and  a  tumid  belly;  it  is  disinclined 
for  exertion  and  has  a  capricious  appetite ;  it  is  liable  to 
night-sweats  and  night-terrors ;  enlarged  glands  are  often 
noted,  the  teeth  appear  behind  time,  and  the  fontanels  close 
late.  The  long  bones  become  much  curved,  the  upper  part 
of  the  chest  sinks  in,  curvature  of  the  spine  appears,  the 
head  is  large  and  the  forehead  bulges,  and  the  pelvis  is 
distorted.  Swelling  appears  in  the  articular  heads  of  long 
bones,  by  the  side  of  the  epiphyseal  cartilages,  and  in  the 
sternal  end  of  the  ribs,  forming  in  the  latter  case  rhachitic 
beads.  The  lesions  of  rickets  are  due  to  imperfect  ossi- 
fication of  the  animal  matter  which  is  prepared  for  bone- 
formation,  and  consequently  to  softening  of  the  bones,  which 
causes  them  to  bend.  The  swellings  at  the  articular  heads 
are  due  to  pressure  forcing  out  the  soft  bone  into  rings. 
Rhachitic  children  rarely  grow  to  full  size,  and  the  disease 
is  responsible  for  many  dwarfs.  Most  cases  recover  without 
deformity,  but  the  time  lost  during  the  period  when  active 
development  should  have  gone  on  cannot  be  made  up,  and 
some  slight  deficiency  is  sure  to  remain.     Bowlegs,  knock- 

'  Brit.  Med.  Jour.,  1895,  ii.,  444. 


RICKETS.  159 

knees,  and  spinal  curvature  are  usually  rachitic  in  origin. 
The  disease  may  be  associated  with  scurvy,  inherited  syph- 
ilis, or  tuberculosis. 

Treatment. — The  treatment  consists  in  open  air,  sunshine, 
salt-water  baths,  sea-air,  fresh  food  (milk,  cream,  and  meat- 
juice),  cod-liver  oil,  syrup  of  the  iodid  of  iron,  arsenic,  and 
some  form  of  phosphorus.  It  is  absolutely  necessary  to 
improve  the  primary  assimilation. 

Scurvy. — This  disease  is  rare  to-day  in  adults,  but  was 
at  one  time  very  common  among  those  who  took  long 
voyages,  or  who  engaged  in  campaigns,  or  were  the  victims 
of  sieges.  Of  recent  years  it  is  very  uncommon,  and  has 
occurred  chiefly  among  voyagers  in  the  Arctic  regions. 

It  is  a  constitutional  malady  due  to  the  consumption  of 
improper  diet,  and  especially  to  the  employment  of  a  diet 
characterized  by  the  absence  of  vegetables. 

The  use  of  salt  meat  as  a  staple  article  seems  to  favor  the 
production  of  the  disease.  Garrod  considered  absence  of 
potassium  salts  to  be  the  real  cause.  Absence  of  variety  in 
diet,  bad  water,  poorly  ventilated  quarters,  and  insufficient 
exercise  favor  the  development  of  the  disease. 

The  disease  begins  by  weakness,  drowsiness,  muscular 
pains,  and  great  susceptibility  to  cold.  The  skin  is  pallid 
or  dirty  white,  and  is  occasionally  mottled  and  often  peels 
off.  The  pulse  is  excessively  weak  and  slow.  There  is  no 
fever.  After  two  or  three  weeks  the  gums  become  tender, 
painful,  and  swollen,  and  bleed  at  frequent  interv^als ;  the 
breath  becomes  offensive,  the  teeth  loosen  and  even  drop 
out ;  subcutaneous  hemorrhages  take  place,  giving  rise  to 
petechise  or  extensive  extravasations ;  the  vision  becomes 
dim,  the  urine  becomes  scanty  and  of  low  specific  gravity ; 
vesicles  form,  rupture,  and  give  rise  to  bleeding  ulcers,  and 
ulcers  likewise  arise  from  breaking  down  of  blood  extravasa- 
tions {American  Text-Book  of  Surgery') ;  hemorrhages  take 
place  into  and  between  the  muscles,  and  in  severe  cases  be- 
neath the  periosteum  and  into  joints,  and  blood  may  come 
from  the  nose,  lungs,  kidneys,  stomach,  and  intestines.  Deep 
hemorrhages  are  felt  as  hard  lumps.  Bleeding  at  an  epiph- 
yseal line  may  separate  the  epiphysis  from  the  shaft.  If 
an  inflammation  or  ulceration  arises  at  any  point,  fever  is 
observed.  It  was  observed  in  the  expedition  in  search  of 
Sir  John  Franklin  that  scurvy  causes  old  and  soundly  healed 
wounds  to  ulcerate.  Most  cases  get  well  under  treatment, 
but  complete  recovery  is  not  attained  for  a  long  time.  It 
is   important  to  remember  that  though  scurvy  is  rare  in 


l6o  MODERN  SURGERY. 

adults,  it  is  by  no  means  uncommon  in  ill-nourished  infants. 
The  author  has  seen  two  cases  in  one  of  which  a  large  sub- 
periosteal hemorrhage  was  mistaken  for  sarcoma  of  the 
femur.     It  may  exist  with  rickets. 

Treatment. — Vinegar,  lemon  juice,  onions,  cider,  nitrate 
of  potassium,  antiseptic  mouth  washes,  strychnin,  plenty  of 
nourishing  food,  and  whiskey  or  brandy.  Secure  sleep ; 
treat  ulcers  by  antiseptic  dressings  and  compression. 

Scurvy  can  be  prevented  entirely  by  securing  a  proper 
diet,  and  maintaining  cleanliness  and  hygienic  conditions 
{American  Text-Book  of  Surgery). 

The  following  agents  are  believed  to  be  especially  useful 
as  preventives  :  fresh  meat,  lemon  juice,  cider,  vinegar,  milk, 
eggs,  onions,  cranberries,  cabbages,  pickles,  potatoes,  and 
lime  juice. 

Infantile  scurvy  may  exist  alone  or  with  rickets.  It  oc- 
curs most  often  in  the  children  of  the  rich,  those  who  have 
been  brought  up  on  artificial  foods.  It  occurs  between  the 
eighth  and  eighteenth  month.  The  child  is  anemic,  has  gas- 
tro-intestinal  disorder,  spongy  gums,  weakness  of  the  legs, 
general  muscular  tenderness,  night-sweats,  and  often  febrile 
attacks  (Rotch).  May  have  bleeding  beneath  skin  (blue  spots), 
bloody  urine  and  stools,  bleeding  into  joints,  viscera,  or  mus- 
cles. A  subperiosteal  hemorrhage  is  very  dense,  is  tender,  is 
fusiform  in  outline,  and  does  not  fluctuate.  The  limb  at- 
tacked is  flexed,  and  the  child  will  not  move  it.  It  is  some- 
times mistaken  for  sarcoma.  Separation  of  epiphysis  may 
result  from  hemorrhage  between  it  and  the  bone. 

Treatment. — Oranges,  grapes,  meat-juice,  potatoes,  nour- 
ishing food,  tonics,  and  antiseptic  mouth-washes, 

XV.  CONTUSIONS   AND    WOUNDS. 

Contusions. — A  contusion  or  bruise  is  a  subcutaneous 
laceration,  the  skin  above  it  being  uninjured  (as  in  the  abdo- 
men), or  being  damaged  without  a  surface-breach  (as  in  a 
part  overlying  bone),  and  blood  being  effused.  If  a  large 
vessel  is  damaged,  hemorrhage  is  extensive.  An  ecchymosis 
is  diffuse  hemorrhage  over  a  large  area ;  a  hematoma  is  a 
blood-tumor  or  a  circumscribed  hemorrhage.  •  In  a  diffuse 
hemorrhage  the  coagulation  of  fibrin  induces  induration ; 
the  serum  and  leukocytes  are  absorbed ;  the  red  blood-cells 
disintegrate,  and  the  coloring-matter  is  widely  diffused  by 
the  tissue-fluids  (suggillation) ;  and  hemoglobin  is  changed 
into    hematoidin,  which   crystallizes.     In    union   with   these 


CONTi'SIOiVS  AND    WOUNDS.  l6l 

chemical  changes,  color-changes  ensue,  the  part  being  at 
first  red  and  then  becoming  purple,  black,  green,  lemon,  and 
citron.  The  stain  following  a  contusion  is  most  marked  in 
the  most  dependent  area.  A  hematoma  acts  as  an  irritant, 
inflammation  ensues  around  it,  and  it  is  encapsuled  by  em- 
bryonic tissue,  which,  by  organizing  into  fibrous  tissue,  forms 
a  blood-cyst  and  gradually  absorbs  the  fluid  blood,  the  cyst- 
contents  becoming  thicker  and  thicker.  A  fibrous  scar  may 
remain.  A  blood-clot  with  very  much  indurated  surround- 
ing tissue,  giving  a  hard  edge,  is  noticed  after  bruises  of  the 
periosteum.  If  serum  is  not  absorbed,  hematoidin  forms 
and  the  fluid  becomes  clear.  A  hematoma  may  suppurate, 
an  abscess  forming ;  but  this  rarely  happens,  except  in 
drunkards,  although  it  occasionally  occurs  in  persons  who 
do  not  use  alcohol. 

Symptoms. — The  symptoms  are  tenderness,  swelling  and 
numbness,  followed  by  considerable  pain.  The  pain  rarely 
persists  beyond  the  first  twenty-four  hours.  Discolora- 
tion appears  quickly  in  superficial  contusions,  but  only 
after  days  in  deep  ones ;  shock  and  loss  of  function  are 
present  after  severe  contusions.  The  swelling  is  first  due 
to  blood,  and  is  soon  added  to  by  inflammatory  exudation. 

Treatment. — In  a  severe  injury  bring  about  reaction  from 
the  shock.  Local  treatment  consists  of  rest,  elevation,  and 
compression  to  arrest  bleeding,  antagonize  inflammation,  and 
control  swelling.  Cold  is  useful  early  in  most  cases,  but  it  is 
not  suited  to  severe  contusions  or  to  contusions  in  the  debili- 
tated or  aged,  as  in  such  cases  it  may  cause  gangrene.  Lead- 
water  and  laudanum  and  iodin  may  be  used.  In  very  severe 
contusions  employ  heat  and  stimulation.  When  inflamma- 
tion is  subsiding  after  a  contusion,  massage  and  inunctions 
of  ichthyol  should  be  employed.  Massage  and  passive  mo- 
tion are  imperatively  needed  after  contusion  of  a  joint.  A 
contusion  should  never  be  incised  unless  hemorrhage  con- 
tinues, infection  takes  place,  or  a  lump  remains  for  some 
weeks.  For  persistent  bleeding  freely  lay  open  the  contused 
area,  turn  out  clots,  ligate  vessels,  insert  drainage  strand  or 
tube,  and  close  the  wound.  If  gangrene  is  feared,  apply  heat 
to  the  part  and  use  iodin  locally,  and  if  a  slough  forms,  em- 
ploy antiseptic  fomentations.  Constitutional  treatment  for 
contusion  is  the  same  as  that  for  inflammation. 

Wounds. — A   wound   is   a   breach   of  surface-continuity 
effected  by  a  sudden  mechanical  force.     Wounds  are  divided 
into   open   and   subcutaneous,  septic  and  aseptic,  contused,, 
incised,  lacerated,  punctured,  gunshot,  and  poisoned. 
11 


1 62  MODERN  SURGERY. 

The  local  phenomena  of  wounds  are  pain,  hemor- 
rhage, loss  of  function,  and  gaping  or  retraction  of  edges. 

Pain  is  due  to  the  injury  of  nerves,  and  it  varies  according 
to  the  situation  and  the  nature  of  the  injury.  It  is  influ- 
enced by  temperament,  excitement,  and  preoccupation.  It 
may  not  be  felt  at  all  at  the  time  of  the  injury.  At  first  it 
is  usually  acute,  becoming  later  dull  and  aching.  In  an  asep- 
tic wound  the  pain  is  slight,  but  in  an  infected  wound  it  is 
severe. 

The  nature  and  amount  of  hemorrhage  vary  with  the  state 
of  the  system,  the  vascularity  of  the  part,  and  the  variety  of 
injury. 

Loss  of  function  depends  on  the  situation  and  extent  of 
the  injury. 

Gaping  or  Retraction  of  Edges. — Due  to  tissue-elasticity. 

The  constitutional  condition  after  a  severe  injury  is  a 
state  known  as  sJiock,  which  is  a  sudden  depression  of  the 
vital  powers  arising  from  an  injury  or  a  profound  emotion 
acting  on  the  nerve-centers  and  inducing  vasomotor  paresis, 
the  blood  accumulating  in  the  abdominal  vessels  and  the 
amount  of  circulating  blood  being  much  diminished.  The 
term  collapse  is  used  by  some  to  designate  a  severe  condi- 
tion of  shock,  and  is  employed  by  others  as  a  name  for  a 
condition  of  shock  produced  by  mental  disturbance  rather 
than  by  physical  injury.  Shock  may  be  slight  and  transient, 
it  may  be  severe  and  prolonged,  and  it  may  even  produce 
almost  instant  death.  It  is  more  severe  in  women  than  in 
men,  in  the  nervous  and  sanguine  than  in  the  lymphatic,  in 
those  weakened  by  suffering  than  in  those  who  are  strangers 
to  illness.  Injury  of  the  abdomen  produces  great  shock,  and 
so  does  damage  to  the  viscera,  the  urethra,  and  the  testicles. 
•Cerebral  concussion  is  a  form  of  shock  plus  other  conditions. 
Sudden  and  profuse  hemorrhage  causes  shock ;  so,  often, 
does  anesthetization. 

Symptoms. — The  symptoms  of  ordinary  shock  (torpid  or 
apathetic  shock)  are  a  subnormal  temperature ;  irregular, 
weak,  rapid,  and  compressible  pulse ;  cold,  pallid,  clammy, 
or  profusely  perspiring  skin  ;  shallow  and  irregular  respira- 
tion ;  and  a  tendency  to  urinary  suppression.  Consciousness 
is  usually  maintained,  but  there  is  an  absence  of  mental  orig- 
inating power,  the  injured  person  answering  when  spoken 
to,  but  volunteering  no  statements  and  lying  with  partly 
closed  lids  and  expressionless  countenance  in  any  position  in 
which  he  may  be  placed.  The  pupils  are  dilated  and  react 
but  slowly  to  hght.     Pain  is  slightly  or  not  at  all  appreci- 


CONTUS/OiVS  AND    WOUNDS.  1 63 

ated.  Vomiting  may,  as  in  concussion,  presage  reaction. 
Gastric  regurgitation  after  a  considerable  duration  of  shock 
is  not  unusual,  and  is  a  bad  omen.  Shock  is  not  rarely  fol- 
lowed by  suppression  of  urine.  If  delirium  arises,  the  con- 
dition is  very  grave  (delirious  shock).  Travers  called  shock 
with  delirium  erethistic  shock.  It  is  seen  typically  after  poi- 
soning from  a  serpent-bite.  As  a  matter  of  fact,  such  a  state  is 
not  genuine  shock,  but  is  either  a  traumatic  or  a  toxic  delir- 
ium. Many  years  ago  Travers  described  a  secondary  or  de- 
layed form  of  shock,  which  comes  on  several  hours  after  an 
injury  or  violent  emotional  disturbance.  This  form  of  shock 
is  seen  not  unusually  in  those  injured  in  a  railroad  accident. 
It  may  be  a  sign  of  hemorrhage,  and  is  sometimes  met  with 
after  the  administration  of  ether  or  chloroform. 

Diagnosis. — Concealed  hemorrhage  is  difficult  to  separate 
from  shock.  It  produces  impairment  of  vision  (retinal  ane- 
mia), irregular  tossing,  frequent  yawning,  great  thirst,  nausea, 
and  sometimes  convulsions.  In  shock  the  hemoglobin  is 
unaltered ;  in  hemorrhage  it  is  enormously  reduced  (Hare 
and  Martin).  In  hemorrhage  recurrent  attacks  of  syncope 
are  met  with.  In  pure  shock  such  attacks  do  not  occur.  In 
concealed  hemorrhage  the  abdomen  may  exhibit  physical 
signs  of  a  rapidly  increasing  collection  of  fluid.  Shock  and 
hemorrhage  are  often  associated.  The  essential  character- 
istic of  shock  is  sudden  onset,  which  separates  it  distinctly 
from  exhaustion.  It  arises  at  a  much  earlier  period  after  an 
injury  than  does  fat-embolism. 

Treatment. — In  treating  ordinary  apathetic  shock  raise  the 
feet  and  lower  the  head,  unless  this  position  causes  cyanosis. 
At  least  place  the  head  flat  and  the  body  recumbent.  Apply 
hot  bottles  and  hot  blankets,  and  give  hypodermatic  injections 
of  ether,  brandy,  strychnin,  digitalis,  or  atropin,  or  inhala- 
tions of  amyl  nitrite.  Strychnin  can  be  used  in  large  doses  ; 
gr.  ^  can  be  given  every  10  or  15  minutes  until  3  doses  are 
taken.  If  the  skin  is  very  moist,  atropin  is  indicated,  alone 
or  combined  with  strychnin.  A  turpentine  enema  is  useful. 
Hot  coffee  or  other  hot  fluids  should  be  given  by  the  mouth 
and  rectum,  and  mustard  should  be  placed  over  the  heart, 
spine,  and  shins.  The  use  of  hot  and  stimulating  rectal  ene- 
mata  is  very  important.  The  rectum  may  absorb  when  the 
stomach  refuses  to  do  so.  Enemata  of  hot  normal  salt  solu- 
tion are  very  beneficial  (enteroclysis).  The  tube  is  carried 
into  the  sigmoid  flexure  and  the  injection  is  introduced  so  as 
to  distend  the  colon.  In  severe  cases  bandage  the  extrem- 
ities in  order  to  send  blood  to  the   brain  and  correct  the 


164  MODERN  SURGERY. 

ischemia  of  the  vital  centers.  For  this  purpose  ordinary 
muslin  bandages  may  be  used,  or  gauze  bandages,  or  the 
bandage  of  Esmarch  (autotransfusion).  Abdominal  massage 
helps  drive  out  the  imprisoned  blood,  and  after  massage  sets 
free  the  abdominal  blood  apply  a  compress  and  binder.  Hy- 
podermoclysis  is  of  great  value.  Insert  an  aspirator-tube 
into  the  cellular  tissue  of  the  buttock,  loin,  or  scapular  re- 
gion, cleansing  the  part  first.  The  tube  is  attached  to  a 
fountain-syringe,  which  is  filled  with  normal  salt  solution, 
and  is  hung  at  a  height  of  two  or  three  feet  above  the  bed. 
In  an  hour's  time  a  pint  or  more  of  fluid  will  enter  the  tis- 
sue and  be  absorbed.  In  very  dangerous  cases  transfuse 
salt  solution  into  a  vein  (p.  277)  and  make  artificial  respira- 
tion, and  stimulate  the  diaphragm  with  a  galvanic  current. 
If  shock  comes  on  during  operation,  the  proceedings  must 
be  hurried  or  even  stopped,  and  proper  treatment  must 
be  instituted  at  once.  The  anesthetizer  should  give  very 
little  ether  when  shock  becomes  at  all  evident.  Should  we 
operate  during  shock  ?  We  should  only  do  so  when  death 
without  instant  operation  is  inevitable.  We  must  operate,  if 
it  is  necessary  to  do  so,  to  arrest  hemorrhage,  to  relieve 
strangulated  hernia,  intestinal  obstruction,  obstruction  of  the 
air-passages,  compound  fractures  of  the  skull,  extravasated 
urine  or  intraperitoneal  extravasations  from  ruptured  viscera. 
If  hemorrhage  can  be  temporarily  controlled  by  pressure  or 
a  clamp  so  much  the  better,  and  the  permanent  arrest  can  be 
effected  after  the  reaction  from  shock.  It  is  not  wise,  in  the 
author's  opinion,  ever  to  amputate  during  shock.  A  tourni- 
quet or  Esmarch  bandage  should  be  applied,  and  attempts 
be  made  to  bring  about  reaction,  and  when  reaction  is  ob- 
tained the  amputation  should  be  performed.  It  is  only  just 
to  say  that  some  eminent  surgeons  oppose  this  rule.  Ros- 
well  Park  says  that  "  shock  is  often  alleviated  by  the  prompt 
removal  of  mutilated  limbs  which,  when  still  adherent  to  the 
trunk,  seem  to  perpetuate  the  condition."  The  same  teacher 
believes  in  operating  at  once  upon  severe  compound  frac- 
tures.^ After  shock  has  passed  away  give  diuretics  to  pre- 
vent suppression  of  urine.  Delayed  shock  is  treated  in  the 
same  manner  as  apathetic  shock  if  hemorrhage  can  be  ex- 
cluded. If  hemorrhage  is  the  cause,  the  bleeding  must  be 
stopped.  If  delirious  shock  is  due  to  sepsis,  the  treatment  is 
the  treatment  of  sepsis.  If  it  is  a  nervous  delirium,  give  mor- 
phin  and  other  sedatives. 
Fat-embolism. — (Seep.  135.) 

^  Park's  Surge;y  by  American  Authors. 


CONTUSIONS  AND    WOUNDS.  1 65 

Fever. — (See  Fevers,  p.  87.) 

Treatment  of  Wounds. — The  rules  for  treating  wounds 
are — (i)  arrest  hemorrhage;  (2)  bring  about  reaction;  (3) 
remove  foreign  bodies  ;  (4)  asepticize  ;  (5)  drain,  coaptate  the 
edges,  and  dress  ;  and  (6)  secure  rest  to  the  part  and  combat 
inflammation.  Constitutionally,  allay  pain,  secure  sleep,  keep 
up  the  nutrition,  and  treat  inflammatory  conditions. 

Arrest  of  HcJiwrrhagc. — To  arrest  hemorrhage  the  bleed- 
ing point  must  be  controlled  by  digital  pressure  until  ready 
to  be  grasped  with  forceps  ;  it  is  then  caught  up  and  tied 
with  catgut  or  aseptic  silk.  Slight  hemorrhage  stops  spon- 
taneously on  exposure  to  air,  and  moderate  hemorrhage 
ceases  after  the  vessels  are  clamped  for  a  time;  an  injured 
vessel  of  some  size  must  be  ligated,  even  if  it  has  ceased  to 
bleed.  Capillary  oozing  is  checked  by  hot-water  compresses. 
If  a  large  artery  is  divided  in  a  limb,  apply  a  tourniquet 
before  ligating  (see  Wounds  of  Vessels). 

Bringing  about  of  Reaction. — (See  Shock.) 

Removal  of  Foreign  Bodies. — Remove  all  foreign  bodies 
visible  to  the  eye  (splinters,  bits  of  glass,  portions  of  cloth- 
ing, gun-wadding,  grains  of  dirt,  etc.)  with  forceps  and  a 
stream  of  corrosive-sublimate  solution.  In  a  lacerated  or 
contused  wound  portions  of  tissue  injured  beyond  repair 
should  be  regarded  as  foreign  bodies  and  be  removed  with 
scissors. 

Cleaning  the  Wonnd. — To  clean  the  wound  scrub  the  area 
around  it  with  ethereal  soap  and  then  with  corrosive-sub- 
limate solution  (i  :  1000).  If  the  surface  is  hairy,  it  must  be 
shaved  before  the  scrubbing.  An  accidental  wound  is  in- 
fected, and  must  be  well  washed  out  with  an  antiseptic  solu- 
tion. A  clean  wound  made  by  the  surgeon  need  not  be 
irrigated;  in  fact,  irrigation  with  an  antiseptic  fluid  leads  to 
necrosis  of  tissues,  causes  a  profuse  flow  of  serum,  and  ne- 
cessitates drainage.  If  clots  have  gathered  in  a  wound  they 
must  be  removed,  as  their  presence  will  prevent  accurate  co- 
aptation of  the  edges.  In  an  infected  wound  they  are  washed 
out  with  a  stream  of  corrosive-sublimate  solution.  In  a  clean 
wound  they  are  washed  out  with  hot  salt  solution.  If  dirt  is 
ground  into  a  wound,  as  is  often  seen  in  crushes,  pour  sweet 
oil  into  the  w^ound,  rub  it  into  the  tissues,  and  scrub  the  wound 
with  ethereal  soap.  The  oil  entangles  the  dirt,  and  the  soap 
and  water  remove  both  oil  and  dirt.  After  the  rough  cleans- 
ing irrigate  with  corrosive-sublimate  solution.  In  some  cases, 
especially  in  bone-injuries,  it  is  necessary  to  scrape  the 
wound  with  a  curet.     If  a  fissure  of  the  skull  is  infected. 


1 66  MODERN  SURGERY. 

enlarge  the  fissure  with  a  chisel  in  order  to  clean  it.  In  a 
bad  infection  one  of  the  most  valuable  agents  for  local  use  is 
pure  carbolic  acid.  In  wounds  which  cannot  be  approxi- 
mated it  is  often  wise  to  employ  grafting  after  the  method 
of  Thiersch.  In  very  small  wounds  which  cannot  be  ap- 
proximated, dust  with  glutol  and  dress  with  dry  sterile  or 
aseptic  gauze ;  and  if  sloughs  form,  apply  antiseptic  poultices 
until  granulation  begins.  A  granulating  wound  is  dressed 
as  a  healing  ulcer. 

Drainage,  Closure,  and  Dressing. — Superficial  wounds  re- 
quire no  special  drain,  as  some  wound-fluid  will  find  exit 
between  the  stitches  and  the  rest  will  be  absorbed.  A  large 
or  deep  wound  requires  free  drainage  for  at  least  twenty-four 
hours  by  means  of  a  tube,  strands  of  horse-hair,  silk,  or 
catgut,  or  bits  of  iodoform  gauze.  An  infected  wound  must 
invariably  be  drained.  Good  drainage  largely  compensates 
for  imperfect  antisepsis.  If  capillary  drains  be  employed, 
apply  a  moist  dressing.  Divided  nerves  and  tendons  must 
be  sutured.  Close  the  edges  with  silk  sutures  or  silkworm- 
gut  if  the  wound  is  deep  and  tension  is  inevitable.  Catgut 
is  used  for  superficial  wounds  and  for  those  where  tension 
is  slight.  The  interrupted  suture  is,  as  a  rule,  the  best. 
If  the  wound  is  infected,  dress  with  antiseptic  gauze ;  or  with 
either  aseptic  or  antiseptic  gauze  if  it  is  not  infected.  The 
custom  once  was  to  cover  the  gauze  with  a  rubber-dam  to 
diffuse  the  fluids,  but  we  now  prefer  to  omit  the  rubber-dam 
and  use  plentiful  dressings.  A  dry  dressing  absorbs  wound- 
fluids  quickly  and  is  less  Hkely  to  become  infected.  Change 
the  dressings  in  twenty-four  hours,  or  sooner  if  they  become 
soaked  with  discharge.  After  this,  in  an  aseptic  wound,  the 
dressing  need  not  be  changed  for  days.  If  pus  forms,  open 
the  wound  at  once.  Many  surgeons  sprinkle  wounds  before 
approximation  and  wound-surfaces  after  approximation  with 
a  drying-powder.  These  powders  are  of  great  use  in  infected 
wounds,  but  are  not  necessary  in  clean  wounds.  Among 
the  substances  employed  are  salicylic  acid,  boracic  acid, 
calomel,  acetanilid,  aristol,  iodoform,  subiodid  of  bismuth, 
and  glutol.  A  sloughing  wound  is  dressed  with  antiseptic 
poultices  after  being  opened  and  dusted  with  protonuclein, 
acetanilid,  glutol,  or  iodoform. 

Rest. — Severe  wounds  require  the  confinement  of  the  pa- 
tient to  bed.  Bandages,  splints,  etc.,  are  used  to  secure  rest. 
The  methods  of  combating  inflammation  have  previously 
been  set  forth. 

Constitutional  Treatment. — Bring  about  reaction  from  de- 


CONTUSIONS  AND    WOUNDS.  167 

pression,  but  prevent  undue  reaction.  Feed  the  patient  well, 
stimulate  him  if  necessary,  and  attend  to  the  bowels  and 
bladder.  Watch  the  temperature  as  the  danger-signal,  se- 
cure sleep,  and  allay  pain.  Look  out  for  complications, 
namely,  inflammation,  suppuration,  gangrene,  tetanus,  and 
erysipelas. 

Incised  Wounds. — An  incised  wound  is  a  clean  cut  in- 
flicted by  an  edged  instrument.  Only  a  thin  film  of  tissue 
is  so  devitalized  that  it  must  die.  These  wounds  have  a 
splendid  chance  of  union  by  first  intention.  A  sword-cut  is 
an  incised  wound. 

Sytnptoms. — The  symptoms  of  incised  wounds  are  sharp 
pain  for  a  time,  followed  by  smarting,  profuse  bleeding,  and 
decided  retraction  of  the  edges. 

Treatment. — The  treatment  of  incised  wounds  is  according 
to  general  rules.  Do  not  use  styptics,  as  they  cause  a  large, 
soft  clot  to  form,  produce  irritation,  and  favor  infection. 

Lacerated  and  Contused  Wounds, — A  lacerated  wound 
is  a  tearing  apart  of  the  tissues  ;  a  contused  wound  is  a  crush- 
ing and  pulpefying  of  tissues.  These  two  forms  may  be 
combined.  They  are  irregular,  contain  masses  of  partially 
detached  tissue  and  blood-clots,  and  their  edges  are  cold  and 
discolored.     Such  wounds  tend  to  necrosis. 

Symptoms. — The  symptoms  are  excessive  shock,  slight 
hemorrhage,  and  only  a  moderately  dull  pain.  Reactionary 
and  secondary  hemorrhages  are  common.  Infection  is  liable 
to  occur,  and  more  or  less  sloughing  is  bound  to  ensue. 

Treatment. — Any  damaged  vessel,  whether  it  bleeds  or 
not,  is  to  be  tied,  the  devitalized  tissues  are  cut  away,  and 
foreign  bodies  are  removed.  Asepticize  with  great  care  and 
secure  thorough  drainage,  making  if  necessary  counter-open- 
ings. In  dressing,  put  iodoform  in  the  wound  and  close  the 
wound  only  partially.  Watch  for  bleeding  during  reaction. 
When  sloughing  begins  use  antiseptic  fomentations.  A 
brush-burn,  which  is  a  contused-lacerated  wound  due  to  fric- 
tion, requires  the  use  of  an  antiseptic  poultice  until  the  slough 
is  cast  ofl".  In  badly  lacerated  wounds  and  crushes  it  is  often 
necessary  to  amputate. 

Punctured  wounds  are  wounds  made  by  pointed  instru- 
ments. A  punctured  wound  is  usually  deep,  it  closes  partly 
after  withdrawal  of  the  instrument,  blood-clot  and  wound- 
fluids  cannot  get  exit,  and  infection  is  almost  certain  if  the 
instrument  carried  microbes.  The  danger  is  not  only  of  in- 
fection by  pus  organisms,  but  by  tetanus  bacteria.  Large- 
sized  foreign  bodies  may  be  driven  in  or  a  portion  of  the  in- 


1 68  MODERN  SURGERY. 

strument  may  break  off.  Arrow-wounds  are  punctured  and 
incised.  Bayonet-wounds  are  punctured,  and  so  are  sticks 
from  a  sword. 

Symptoms. — In  punctured  wounds  the  pain  is  rarely  severe, 
and  hemorrhage  is  slight  unless  a  large  vessel  be  wounded. 
Infection  is  apt  to  ensue.  Varicose  aneurysm  may  be  caused 
if  both  a  vein  and  an  artery  have  been  punctured. 

Treatment. — In  treating  punctured  wounds  incise  to  the 
depth  of  the  puncture,  stop  the  hemorrhage,  asepticize  with 
pure  carbolic  acid  in  many  cases,  and  drain.  An  arrow 
should  never  be  pulled  out,  but  should  be  pushed  through 
or  cut  down  upon  by  enlarging  the  wound. 

Gunshot-wounds. — Gunshot -wounds  are  contused  or 
contused-lacerated  wounds  inflicted  by  materials  projected  by 
explosives.  A  bit  of  rock  or  a  crowbar  hurled  by  dynamite 
inflicts  a  gunshot-wound,  as  does  a  shell-fragment,  a  pistol- 
ball,  a  small  birdshot,  a  rifle-bullet,  a  flying  cap,  a  piece  of 
wadding,  grains  of  powder,  a  buckshot,  a  fragment  of  wood 
broken  off  by  a  shell  concussion,  grapeshot  and  canister, 
or  a  cannon-ball.  Injuries  by  shell-fragments,  portions  of  a 
bursted  boiler,  pieces  of  masonry  or  wood,  are  either  lacer- 
ated or  punctured  wounds,  and  need  no  special  consideration 
here.  In  this  article  we  treat  of  injuries  caused  by  bullets 
and  shot. 

At  the  present  day  the  old  round  ball  is  very  rarely  used, 
the  conical  projectile  having  taken  its  place.  For  the  fire- 
arms of  civilians,  as  a  rule,  the  bullets  are  made  of  lead, 
hardened  and  shaped  by  compression,  or  hardened  by  an 
admixture  with  tin.  The  conical  shape  of  the  pistol-ball, 
the  great  velocity  with  which  it  is  propelled  and  with 
which  it  rotates,  and  its  hardness,  make  it  unlikely  that 
at  near  range  the  bullet  will  only  contuse  and  not  enter 
the  skin.  It  will  almost  always  enter ;  it  will  occasionally 
lodge  and  often  perforate ;  it  is  rarely  deflected,  and  is  not 
nearly  so  much  flattened  by  impact  as  the  softer  round  ball. 
A  pistol-ball  or  a  spent  rifle-ball,  however,  may  fail  to  enter 
the  tissues,  grazing  the  surface  and  inflicting  a  brush-burn,  or 
simply  contusing  the  part.  A  bullet  may  enter  the  tissues, 
a  cavity,  or  an  organ,  and  lodge  there,  causing  a  penetrating 
wound.  It  may  enter  and  emerge,  causing  a  perforating 
wound.  The  bullet  may  not  enter  alone,  but  may  carry 
with  it  bits  of  clothing  or  other  foreign  bodies.  This  com- 
plication is  much  more  rare  in  injury  by  the  conical  bullet. 

The  military  surgeon  deals  with  wounds  inflicted  by  small, 
densely  hard,  conical  projectiles,  which  are  impelled  at  a 


CONTUSIONS  AND    WOUNDS.  1 69 

great  velocity,  and  are  carried  to  long  distances.  The  old 
Springfield  rifle,  of  a  caliber  of  0.45  inch,  projected  a  bullet 
with  a  velocity  of  thirteen  hundred  feet  in  a  second. 

The  Mannlicher  rifle,  of  a  caliber  of  0.25  to  0.32  inch,  sends 
a  bullet  with  a  velocity  of  over  two  thousand  feet  a  second. 
This  bullet  revolves  with  great  velocity  upon  its  own  axis  (two 
thousand  times  the  first  second)  and  is  effective  at  several  miles. 

The  bullet  of  the  modern  rifle  is  conical,  has  a  leaden  core, 
and  is  hardened  by  being  covered  with  a  mantle  or  jacket 
of  copper,  steel,  nickel,  or  of  alloys  of  copper  and  nickel,  or 
of  copper,  nickel,  and  zinc. 

The  older  projectile  was  apt  to  lodge ;  was  often  deflected 
in  the  tissues ;  was  flattened  out  on  meeting  with  resistant 
structures,  such  as  bone  or  cartilage,  and  after  flattening  be- 
came larger  and  tore  and  lacerated  the  soft  parts  and  com- 
minuted the  bone. 

The  new  projectile  is  apt  to  perforate,  is  rareh'  deflected, 
and  is  so  hard  that  its  shape  is  generally  but  little  altered 
on  meeting  with  resistant  structures,  and  hence  it  was 
thought  that  the  new  bullet  would  prove  more  humane  than 
the  old  projectile,  and  inflict  wounds  which  would  be  more 
easily  treated  than  of  old,  because  the  bullets  would  not 
lodge  and  because  extensive  damage  would  not  be  in- 
flicted. This  view  has  proved  fallacious.  It  is  true  that 
in  many  instances  a  modern  bullet  will  make  a  clear  track 
without  laceration  or  comminution  ;  but  in  other  instances 
it  pulpefies  structure  for  a  considerable  distance  around  the 
track  of  the  ball  by  what  is  known  as  the  explosive  effect. 
This  term  does  not  mean  that  the  bullet  has  exploded,  but 
that  its  sudden  impact  against  and  rapid  rotation  in  the 
tissues  have  by  waves  of  force  caused  extensive  and  dis- 
tant damage,  and  often  horrible  and  irreparable  injury.  Ex- 
plosive effects  are  seen  most  often  at  close  range,  when  the 
velocity  of  the  ball  and  the  frequency  of  its  rotation  are  most 
marked.  A  pistol-ball  has  no  explosive  action  at  all,  and  the 
old-time  bullet  possessed  it  only  at  ver)'  close  range.  The 
modern  projectile  always  produces  explosive  effects  up  to 
five  hundred  yards.  Up  to  thirteen  hundred  yards  it  pro- 
duces them  upon  the  skull  and  brain.  At  this  distance  a 
single  small  projectile  may  entirely  destroy  the  cranium  and 
brain  (see  Demosthen's  studies  of  the  action  of  the  Mann- 
licher rifle).  Explosive  effects  are  noted  at  long  distances 
upon  the  liver,  spleen,  kidney,  and  lungs,  and  upon  hollow 
viscera  containing  fluid. 

Cancellous  bone  struck  by  the  old-style  bullet  was  much 


lyO  MODERN  SURGERY. 

comminuted  at  any  range ;  struck  with  the  new  bullet  at  a 
range  of  from  three  hundred  and  fifty  to  fifteen  hundred 
yards,  perforation  occurs  rather  than  comminution.  At  a 
distance  of  less  than  three  hundred  and  fifty  yards  the  new 
ball  has  an  explosive  effect  and  causes  great  damage.  Hard 
bone  is  extensively  damaged  at  even  long  range  by  the  hard 
projectile.  This  projectile  theoretically  does  not  flatten,  but 
practically  in  many  instances  it  does  flatten  a  little,  and  in 
others  its  coat  is  torn  off  when  it  strikes  hard  bone  at  a  dis- 
tance of  less  than  eighteen  hundred  yards.  The  old-style  bul- 
let rarely  caused  much  primary  hemorrhage,  as  the  vessels 
as  well  as  the  nerves  and  tendons  were  usually  pushed  aside 
rather  than  cut.  Hence  secondary  hemorrhage  was  com- 
mon because  of  contusion  of  the  vessel-walls.  The  modern 
bullet  cuts  rather  than  pushes  aside  the  vessels.  Hence  pri- 
mary hemorrhage  is  usual,  and  may  often  prove  fatal.  The 
modern  bullet  rarely  lodges  at  any  range,  and  is  rarely  de- 
flected. Skin  is  usually  split  by  it.  Fascia  and  muscle  are 
usually  much  damaged,  but  in  a  transverse  wound  of  muscle 
the  fibers  may  be  separated  rather  than  destroyed  (Conner). 
In  the  warfare  of  the  future  numbers  of  the  wounded  will 
be  fortunate  in  not  harboring  a  ball  and  in  escaping  manipu- 
lations to  extract  it.  Great  numbers  of  people  will  be  killed 
outright  and  great  numbers  will  receive  terrible  injuries,  from 
which  recovery,  if  it  takes  place  at  all,  will  be  attained  after 
much  time  and  agony.  The  effects  of  the  modern  bullet 
have  been  determined  by  careful  study  and  experiment ;  by 
a  study  of  the  wounds  in  the  Chitral  Expedition  and  of 
wounds  inflicted  by  accident  or  with  homicidal  or  suicidal 
intent ;  by  experiments :  firing  through  boxes  filled  with 
wet  sand ;  firing  into  thick  oak ;  firing  at  cadavers  at  fixed 
distances  with  reduced  charges  (La  Garde).  Nancrede  cau- 
tions us  to  remember  that  experiments  upon  the  cadaver, 
employing  reduced  charges  and  standing  at  fixed  distances, 
are  uncertain  in  their  provings.  "  The  difference  between 
the  velocity  of  rotation  and  angle  of  incidence  with  reduced 
charges  at  fixed  distances  and  service-charges  at  actual  dis- 
tances are  marked.  The  tension  of  living  muscles  and  fasciae, 
as  compared  with  dead  tissues,  and  the  physical  change  of 
the  semiliquid  fat  of  adipose  tissue  and  medulla  to  a  more  solid 
condition  by  the  loss  of  animal  heat,  influence  the  results.^" 

^  Nancrede  upon  "  Gunshot  Wounds,"  in  Park's  Surgery  by  American  Authors. 
For  information  upon  wounds  by  the  modern  firearm,  see  report  of  Surgeon- 
General  of  the  United  States  Army,  1893.  Demosthen's  study  of  the  wounds 
inflicted  by  the  Mannlicher  rifle.     Prof.  Conner,  in  Dennis'  Syste?ti  of  Surgery. 


CONTUSIONS  AND    WOUNDS.  I/I 

In  injuries  from  the  old-style  bullet  the  wound  of  entrance 
was  often  smaller  than  the  ball  (skin  stretched  at  the  moment 
of  impact  and  contracted  after  perforation) ;  it  was  depressed, 
and  the  edges  were  contused  and  inverted,  and  if  the  weapon 
were  fired  within  ten  feet  usually  were  blackened  from  pow- 
der and  contained  powder-grains.  If  the  wound  was  much 
larger  than  the  bullet,  it  meant  that  some  foreign  body  had 
been  carried  in.  In  injuries  from  the  modern  bullet  the  skin 
may  be  split  or  may  be  perforated,  the  wound  is  usually  as 
large  as  the  ball,  and  foreign  bodies  are  not  carried  by  the 
ball  into  the  tissue. 

In  wounds  from  the  old-style  bullet  the  wound  of  exit  was 
everted,  "  triangular,  linear,  or  stellate,"  and  much  larger  than 
the  wound  of  entrance ;  in  wounds  from  the  modern  bullet, 
if  the  wound  of  exit  is  not  in  the  region  of  explosive  action, 
it  may  be  a  little  larger  or  a  little  smaller  than  the  bullet, 
but  is  not  noticeably  larger  than  the  wound  of  entrance. 
If  within  the  area  of  explosive  action,  the  wound  of  exit  is 
much  larger  than  the  wound  of  entrance,  and  is  irregular 
and  everted. 

Wounds  by  Cannon-balls. — A  cannon-ball  weighing 
five  or  six  pounds  may  be  imbedded  in  tissues.  A  ball  or 
shell-fragments  may  tear  off  a  limb  or  lacerate  it  exten- 
sively. In  some  cases  of  injury  by  spent  balls  the  bone 
is  destroyed  and  the  muscles  disorganized  while  the  skin 
is  intact. 

Wounds  by  Small  Shot. — Single  shot  may  bruise  the 
surface  or  may  enter  the  tissues.  When  many  shot  enter 
together  they  strike  as  a  solid  body.  Single  shot  are  usually 
deflected  from  vessels  and  nerves,  and  rarely  lodge  in  bone, 
but  rather  flatten  on  its  surface.  A  load  of  shot  entering 
together  produces  extensive  laceration  and  inflicts  damage 
which  is  often  irreparable. 

Symptoms  of  a  Gunshot--w"ound. — Hemorrhage  is 
often  considerable,  but  ceases  spontaneously  unless  a  large 
vessel  has  been  divided.  If  hemorrhage  is  profuse,  the  con- 
stitutional symptoms  of  hemorrhage  exist.  These  symp- 
toms are  of  great  importance  in  abdominal  wounds  (p.  628). 
A  pistol-ball  rarely  causes  severe  primary  hemorrhage, 
because  it  rarely  penetrates  a  large  artery.  It  is  apt  to 
push  aside  a  vessel,  and  secondary  hemorrhage  is  not  un- 
usual. Even  if  a  large  vessel  is  wounded  and  a  succession  of 
violent  hemorrhages  occur,  a  man  may  live  for  several  days. 
Secondary  hemorrhage  may  follow  a  gunshot-wound  because 
of  contusion  of  vessels  or  of  infection. 


1/2  MODERN  SURGERY. 

Pain  is  often  not  noticed  at  first,  especially  if  the  injured 
individual  were  greatly  preoccupied  or  excited.  There  may 
be  a  feeling  of  numbness,  but  there  is  usually  a  dull  or 
stinging  pain.  If  a  large  nerve  is  injured,  there  may  be  vio- 
lent pain.  Even  trivial  gunshot-wounds  frequently  produce 
profound  shock,  and  yet  it  may  happen  that  even  severe 
wounds  may  be  accompanied  by  but  slight  shock.  In  most 
gunshot-wounds  of  the  brain,  abdomen,  and  spinal  cord  the 
shock  is  very  great. 

General  Considerations  as  to  Treatment. — The  dangers 
are  shock,  hemorrhage,  and  infection.  Bullets  are  aseptic 
when  they  enter  a  part,  and  if  infection  is  not  inserted  in  the 
track  of  the  ball  the  wound  will  in  most  instances  heal 
kindly.  "  The  fate  of  a  wounded  man  is  in  the  hands  of 
the  surgeon  who  first  attends  him "  (Nussbaum).  The 
danger  of  a  wound  depends  upon  the  size  and  velocity  of 
the  bullet,  the  part  struck,  "  and  the  degree  of  asepsis  ob- 
served during  the  first  examination  and  dressing"  (Nan- 
crede).  The  rules  of  treatment  are :  bring  about  reaction, 
arrest  hemorrhage,  preserve  asepsis,  and,  in  some  cases,  re- 
move the  ball.  Always  notice  if  a  wound  of  exit  exists.  It 
is  a  good  plan,  when  endeavoring  to  determine  the  extent 
of  injury,  to  put  the  parts  in  the  position  they  were  in  when 
the  injury  was  inflicted.  We  should  try  to  ascertain  the 
size  and  nature  of  the  weapon,  and  the  range  at  which  it  was 
fired.  Examine  the  clothing  to  see  if  any  fragments  are 
missing  and  could  have  been  carried  in.  Such  fragments 
render  sepsis  almost  inevitable.  The  surgeon  must  not  feel 
it  his  duty  to  probe  in  all  cases.  In  many  cases  it  is  better 
not  to  probe  at  all.  Explore  for  the  ball  when  sure  that  it 
has  carried  in  with  it  foreign  bodies ;  when  its  presence  at 
the  point  of  lodgement  interferes  with  repair ;  when  it  is  in 
or  near  a  vital  region  (as  the  brain) ;  and  when  it  is  neces- 
sary to  know  the  position  of  the  bullet  in  order  to  determine 
the  question  of  amputation  or  resection.  If  the  wound  is 
large  enough,  the  finger  is  the  best  probe. 

Fluhrer's  aluminum  probe  is  a  valuable  instrument.  It 
is  employed  especially  in  brain-wounds,  and  is  allowed  to 
sink  into  the  track  of  the  ball  by  the  influence  of  gravity 
after  the  part  has  been  placed  in  a  proper  position.  If  a 
lead  bullet  is  imbedded,  it  is  possible  to  distinguish  the  hard 
projectile  from  a  bone  by  inserting  the  stem  of  a  clay  pipe,  a 
bit  of  pine  wood,  or  Nelaton's  porcelain-headed  probe.  On 
any  one  of  these  appliances  lead  will  make  a  black  mark. 
No  such  test  can  be  applied  to  a  modern  bullet,  for  this  has 


COXTi'SWiVS  AND    WOUNDS.  1 73 

a  hard  metal  jacket,  and  will  not  make  a  black  mark  on  a 
white  substance. 

The  induction-balance  of  Graham  Bell  has  been  employed 
to  determine  the  situation  of  a  bullet.  The  bullet  may  be 
located  by  Girdners  telephonic  probe.  In  order  to  construct 
this  instrument,  take  a  telephone  receiver,  fasten  one  of  the 
wires  to  a  metal  plate  and  the  other  one  to  a  metallic  probe. 
Moisten  a  portion  of  the  patient's  body  and  place  the  metal 
plate  in  contact  with  it.  The  surgeon  places  the  receiver 
to  his  ear  and  inserts  the  probe  into  the  w^ound.  If  the 
probe  strikes  metal,  a  click  is  heard  with  distinctness.  A 
bullet  may  be  located  by  LilicntJiaV s  probe.  This  appa- 
ratus consists  of  a  mouth-piece,  two  insulated  copper  wires, 
and  a  probe.  The  mouth-piece  is  composed  of  two  plates, 
one  of  copper  and  one  of  zinc,  which  are  applied  to  the 
sides  of  the  tongue.  An  insulated  wire  runs  from  each 
plate  and  into  the  metal  probe.  The  tip  of  the  probe  is 
composed  of  two  or  four  pieces  of  metal,  is  separated  from 
the  shank  by  a  washer  of  rubber,  and  is  attached  to  the 
wires.  The  operator  closes  the  teeth  upon  the  mouth- 
piece and  inserts  the  probe  into  the  wound.  If  the  probe 
touches  the  bullet,  a  distinct  and  continuous  metallic  taste 
is  appreciable. 

The  best  means  of  discovering  a  bullet  is  to  use  the  fluoro- 
scope  or  take  a  skiagraph.  In  order  to  locate  it  accurately 
view  it  through  a  series  of  squares,  insert  guide-pins,  or 
employ  Sweet's  apparatus  (p.  875).  Bullets  are  readily 
seen  in  the  superficial  soft  parts,  but  are  also  recognizable 
in  deeper  structures  (bone,  abdomen,  lung,  brain,  etc.). 

Though  Nelaton's  probe  will  not  show  the  difference  be- 
tween ball  and  bone,  it  is  a  valuable  instrument  to  follow  the 
track  of  a  wound.  The  porcelain  head  ought  to  be  larger 
than  it  is  usually  made — in  fact,  it  should  be  nearly  the  size 
of  the  bullet  (Senn). 

In  passing  a  probe  use  no  more  force  than  in  passing  a 
catheter  (Senn).  In  extracting  the  ball  use  very  strong 
forceps.  The  old  American  bullet-forceps  is  useless  for  the 
extraction  of  the  hard-jacketed  ball,  as  the  points  of  the  in- 
strument will  not  penetrate  and  the  instrument  will  not  hold. 

If  hemorrhage  is  severe  in  a  gunshot-wound,  enlarge  the 
wound,  find  the  bleeding  vessel,  and  tie  it.  Before  handling 
a  gunshot-wound  asepticize  the  parts  about  it.  Irrigate  with 
hot  sterile  salt  solution,  and  drain  with  a  tube  or  a  bit  of 
iodoform  gauze  and  dress  antiseptically.  Primaiy  union 
rarely  takes  place  because  of  the  necrosis  of  damaged  tissue 


1/4  MODERN  SURGERY. 

in  the  track  of  the  ball,  but  in  some  cases  it  can  be  obtained. 
Healing  begins  in  the  depths  of  the  wound  and  extends 
toward  the  wound  of  entrance,  or,  if  there  be  also  a  wound 
of  exit,  toward  both.  Radical  operations  may  be  demanded  : 
laparotomy  (p.  666),  trephining  (p.  571),  rib-resection  (p.  610), 
joint-resection,  and  amputation. 

Amputation  is  sometimes  demanded  because  of  great 
injury  to  the  soft  parts  (as  by  a  shell-fragment),  the  splinter- 
ing of  a  bone,  injury  of  a  joint,  damage  to  the  chief  vessels 
or  nerves,  or  the  destruction  of  a  considerable  part  of  a 
limb.  Perform  a  primary  amputation  if  possible,  and  make 
the  flaps  through  tissue  that  will  not  slough.  In  civil  prac- 
tice, with  careful  antisepsis,  more  questionable  tissue  can  be 
admitted  into  a  flap  than  in  military  practice,  where  trans- 
portation will  become  necessary  and  antisepsis  may  be  im- 
perfect or  wanting. 

In  warfare  at  the  present  day  an  attempt  is  made  to  limit 
the  death-rate  from  gunshot-wounds  by  protecting  them 
from  infection  at  an  early  period  after  the  accident.  Es- 
march  offered  a  suggestion,  which  has  been  adopted  in  the 
German  army  and  other  armies.  Every  soldier  carries  a 
package  which  contains  antiseptic  dressings,  and  at  the  first 
opportunity  after  the  infliction  of  a  wound,  if  possible  on  the 
field,  these  dressings  are  applied  by  the  soldier  or  by  a  com- 
rade (for  even  the  privates  are  instructed  in  the  application), 
or  by  an  ambulance  man.  If  not  applied  on  the  field,  they 
are  applied  at  the  first  dressing-station  by  a  surgeon  or  a  hos- 
pital steward.  Senn  considers  Esmarch's  package  too  cum- 
brous.^ He  suggests  a  package  containing  half  an  ounce  of 
compressed  salicylated  cotton.  In  the  center  of  this  cotton 
is  an  antiseptic  powder  (2  gm.  of  boric  acid  and  \  gm.  of 
salicylic  acid).  The  cotton  is  wrapped  in  a  triangular  gauze 
bandage.  A  safety-pin  is  placed  in  the  bandage  and  the  en- 
tire bundle  is  wrapped  in  gutta-percha  tissue.  Senn  says  the 
triangular  bandage  is  sufficient  to  hold  on  a  dressing,  and  it 
can  be  assisted  by  utilizing  the  gunstrap,  safety-belt,  or  articles 
of  clothing.^  (For  gunshot-wounds  of  special  structures,  see 
Bones,  Joints,  etc.) 

Poisoned  wounds  are  those  in  which  a  poison  is  intro- 
duced. This  poison  may  be  microbic  and  capable  of  self- 
multiplication,  or  it  may  be  chemical,  and  hence  incapable 
of  multiplication.     There  are  three  classes  of  poisons:^  (i) 

"^  Jour.  Ajn.  Med.  Assoc,  July  13,  1895. 

^  Senn,  m  Jour.  Am.  Med.  Assoc.,  July  13,  1895. 

'  American  Text-Book  of  Surgery. 


CONIX'SIONS  AND    WOUNDS.  1 75 

mixed  infection,  as  septic  wounds,  dissection-wounds,  and 
malignant  edema ;  (2)  chemical  poison,  such  as  snake-bites 
and  insect-stings  ;  and  (3)  infection  by  such  diseases  as  rabies, 
glanders,  etc. 

Septic  wounds  are  those  which  putrefy,  suppurate,  or 
slough.  Open  septic  wounds  freely  for  drainage,  curet,  or 
cut  away  hopelessly  damaged  tissue,  wash  with  peroxid  of 
hydrogen  and  then  with  corrosive  sublimate,  dust  with  iodo- 
form or  glutol,  and  either  use,  a  drainage-tube  or  pack  with 
iodoform  gauze.  The  antiseptic  poultice  is  an  excellent 
dressing.  If  lymphangitis  arises,  paint  over  the  inflamed 
vessels  and  glands  with  iodin  and  cover  with  lead-water 
and  laudanum,  and  give  internally  quinin  and  iron.  Watch 
the  temperature  for  evidences  of  general  infection  or  intox- 
ication. Stimulate  and  secure  good  nourishment,  rest,  and 
sleep. 

Dissection-wounds  are  simple  examples  of  infected 
wounds,  and  they  present  nothing  peculiar  except  virulence. 
They  affect  butchers,  cooks,  surgeons  who  cut  themselves 
in  operating  on  an  infected  area,  those  who  make  postmor- 
tems, and  those  who  dissect.  A  dissection-wound  inflicted 
while  working  on  a  body  injected  with  chlorid  of  zinc  pos- 
sesses but  few  elements  of  danger  unless  the  health  of  the 
student  is  much  broken  down.  Postmortems  are  peculiarly 
dangerous  when  the  subject  has  died  of  some  septic  process. 
When  a  wound  is  inflicted  while  dissecting,  wash  it  under  a 
strong  stream  of  water,  squeeze,  and  suck  it  to  make  the 
blood  run,  lay  it  open  if  it  be  a  puncture,  swab  it  out  with 
pure  carbolic  acid,  and  dress  it  with  iodoform  and  gauze. 
If  infection  shows  itself,  it  must  be  treated  as  any  other 
infected  wound. 

Malignant  edema  or  gangrenous  emphysema  arises 
most  commonly  after  a  puncture.  It  is  due  to  a  specific 
bacillus  which  produces  great  edema,  and  to  secondary  infec- 
tion with  putrefactive  organisms. 

Symptoms. — The  symptoms  are  edema,  the  fluid  being 
distinctly  bloody,  followed  by  rapidly  diffusing  gangrene 
which  is  surrounded  by  a  zone  of  edematous  tissue  that 
crepitates  under  pressure  because  it  contains  gases  of  putre- 
faction. The  zone  of  edema  is  covered  with  blebs  which 
contain  thin,  putrid,  reddish  matter.  The  constitutional  con- 
dition is  one  of  septicemia.  Death  occurs,  as  a  rule,  in  a 
few  days. 

Treatment. — To  treat  malignant  edema,  if  it  affect  a  limb, 
amputate  at  once,  high   up.     If  it  affect  some  other  part, 


176  MODERN  SURGERY. 

excise,  use  the  actual  cautery,  and  dress  antiseptically. 
Stimulate  very  freely. 

Stings  and  Bites  of  Insects  and  Reptiles :  Stings 
of  Bees  and  Wasps. — A  bee's  sting  consists  of  two  long 
lances  within  a  sheath  with  which  a  poison-bag  is  connected. 
The  wound  is  made  first  by  the  sheath,  the  poison  then 
passes  in,  and  the  two  lances,  moving  up  and  down,  deepen 
the  cut.  The  barbs  on  the  lances  make  it  difficult  to  rapidly 
withdraw  the  sting,  which  may  be  broken  off  and  remain  in 
the  flesh.  Besides  bees,  hornets,  yellow-jackets,  and  other 
wasps  produce  painful  stings.  These  stings  rarely  produce 
any  trouble  except  pain  and  swelling.  In  some  rare  cases  a 
bee-sting  is  fatal ;  persons  have  been  stung  to  death  by  a 
great  number  of  these  insects. 

Symptoms. — If  general  symptoms  ensue,  they  appear 
rapidly  and  consist  of  great  prostration,  vomiting,  purging, 
and  delirium  or  unconsciousness.  These  symptoms  may 
disappear  in  a  short  time,  or  they  may  end  in  death  from 
heart-failure.  Stings  of  the  mouth  may  cause  edema  of  the 
glottis. 

Treatment. — To  treat  a  bee-sting,  extract  the  sting  if  it 
be  broken  off,  and  apply  locally  ichthyol,  a  solution  of  wash- 
ing-soda, tincture  of  arnica,  iodin,  or  lead-water  and  lauda- 
num.    If  constitutional  symptoms  appear,  stimulate. 

Other  Insect-bites  and  Stings. — The  mandibles  of  a 
spider  are  terminated  by  a  movable  hook  which  has  an 
opening  for  the  emission  of  poison.  The  bite  of  large 
spiders  is  productive  of  inflammation,  swelHng,  weakness, 
and  even  death.  The  bite  of  the  poisonous  spider  of  New 
Zealand  produces  a  large  white  swelling  and  great  prostra- 
tion ;  death  may  ensue,  or  the  victim  may  remain  in  a  de- 
pressed, enfeebled  state  for  weeks  or  even  for  months.  The 
tarantula  is  a  much-dreaded  spider.  A  scorpion  has  in  its 
tail  a  sting,  and  a  scorpion's  sting  produces  great  prostration, 
delirium,  vomiting,  diaphoresis,  vertigo,  headache,  local  swell- 
ing, and  burning  pain,  followed  often  by  suppuration,  or  even 
by  gangrene  and  fever.  Centipedes  must  be  of  large  size 
to  be  formidable  to  man,  and  the  symptoms  arising  from 
their  stings  are  usually  only  local. 

Treatment. — Tie  a  fillet  above  the  bitten  point ;  make  a 
crucial  incision,  favor  bleeding,  and  swab  out  the  wound  with 
pure  carbolic  acid  or  some  caustic  or  antiseptic  (if  in  the 
wilds,  burn  with  fire  or  gunpowder) ;  dress  antiseptically  if 
possible,  and  stimulate  as  constitutional  symptoms  appear. 
Slowly  loosen  the  ligature  after  symptoms  disappear.    Chlo- 


CONTUSIONS  AND    WOUNDS.  1/7 

roform  stupes  and  ipecac  poultices  are  recommended,  also 
puncture  with  a  needle  and  rubbing  in  a  mixture  of  3  parts 
of  chloral  and  i  part  of  camphor  (Bauerjie). 

Snake-bites. — The  poisonous  snakes  of  America  com- 
prise the  copperheads,  water-moccasins,  rattlesnakes,  and 
vipers.  There  is  also  a  poisonous  lizard.  The  symptoms 
of  snake-bite  are  similar  whether  it  is  the  bite  of  an  Indian 
cobra  or  of  an  American  rattler,  and  they  depend  upon 
the  dose  of  poison  introduced.  Poison  injected  into  a  vein 
may  prove  almost  instantly  fatal.  The  poison  is  not  ab- 
sorbed by  the  sound  mucous  membranes.  It  is  discharged 
through  the  hollow  fangs  of  the  reptile  by  contractions  of 
the  muscles  of  the  poison-bag.  In  most  varieties  of  snakes 
the  teeth  lie  along  the  back  of  the  mouth  and  are  only 
erected  when  the  reptile  strikes.  The  poison  contains  pro- 
teid  constituents,  globulins,  and  peptones  (Mitchell  and 
Reichert),  and  probably  toxic  animal  alkaloids  (Brieger). 
S.  Weir  Mitchell  has  shown  that  rattlesnake  venom  exerts 
a  paralyzing  action  upon  the  walls  of  the  smaller  blood- 
vessels, converts  the  blood  into  a  noncoagulable  fluid,  causes 
the  white  blood-cells  and  the  fluid  elements  of  blood  to  ex- 
travasate  into  the  tissues,  and  disintegrates  the  red  corpuscles. 

Symptoms. — The  symptoms  are — pain,  soon  becoming 
intense ;  mottled  swelling  of  the  bitten  part,  which  swelling 
may  be  enormous,  and  which  is  due  to  edema  and  extrava- 
sation of  blood,  and  assumes  a  purpuric  discoloration. 
There  may  be  complete  consciousness,  or  there  may  be 
lethargy,  stupor,  or  coma.  Some  cases  present  spasms. 
The  general  symptoms  are  those  of  profound  shock,  which 
may  present  delirium  (delirious  shock).  Death  may  arise 
from  paralysis  of  the  heart  or  paralysis  of  respiration,  and 
may  occur  in  about  five  hours,  but  as  a  rule  it  is  postponed 
for  a  number  of  hours.  If  death  is  deferred  many  hours, 
profound  sepsis  comes  upon  the  scene,  with  glandular  en- 
largement, suppuration,  and  sometimes  gangrene. 

Treatment. — Cases  of  snake-bite  must,  as  a  rule,  be  treated 
without  proper  appliances.  The  elder  Gross  was  accus- 
tomed to  relate  in  his  lectures  how  he  hacd  seen  an  army 
officer  blow  off  his  finger  with  a  pistol  the  moment  it  was 
struck,  and  thus  escape  poisoning.  In  general,  the  rules 
are  to  twist  several  fillets  at  different  levels  above  the  bite, 
to  excise  the  bitten  area,  to  suck  or  cup  it  if  possible,  and 
to  cauterize  it  by  a  pure  acid  or  by  heat.  An  expedient 
among  hunters  is  to  cauterize  by  pouring  gunpowder  on  the 
excised  area  and  applying  a  spark,  or  by  laying  a  hot  ember 
12 


178  MODERN  SURGERY. 

on  the  wound.  When  a  hot  iron  is  available,  use  it.  The 
.fillets  are  not  to  be  removed  suddenly,  and  they  had  best  be 
kept  on  for  some  time.  Remove  the  highest  constricting 
band  first ;  if  no  symptoms  come  on  after  a  time,  remove 
the  next,  and  so  on ;  if  symptoms  appear,  reapply  the  fillet. 
The  constitutional  treatment  is  expressed  in  one  word : 
stimulate.  Our  only  hope  is  in  large  doses  of  alcohol,  and, 
if  they  can  be  obtained,  ammonia,  ether,  strychnin,  or  digi- 
talis hypodermatically  administered.  Large  doses  of  strych- 
nin hypodermatically  are  used  by  many  surgeons  in  India. 
Morphin  may  be  given  for  pain.  There  is  no  specific  for 
snake-poison.  Hypodermatic  injections  in  the  area  adjacent 
to  the  bite  of  a  i  per  cent,  solution  of  the  permanganate 
of  potassium  are  commended  by  some.  The  local  use  of 
chlorid  of  lime  has  recently  been  recommended.  Halford  of 
Australia  praises  the  intravenous  injection  of  ammonia  (loTTL 
of  strong  ammonia  in  2oTrL  of  water).  If  a  man  is  bitten  by 
a  large  and  deadly  snake,  the  surgeon,  if  one  is  at  hand, 
should  at  once  amputate  well  above  the  bite.^  Attempts  are 
being  made  to  obtain  a  curative  serum.  Animals  can  be  ren- 
dered immune  by  giving  them  at  first  small  doses  of  the 
poison  and  gradually  increasing  the  amount  administered. 
It  is  asserted  that  the  serum  of  immune  animals  will  cure  a 
person  bitten  by  a  venomous  snake.  Cures  have  been  re- 
ported after  the  use  of  Calmette's  antivenene  serum.  The 
dose  is  20  c.c.  hypodermatically,  repeated  if  necessary  in  three 
or  four  hours.  Alexander^  treated  a  case  successfully  by 
making  an  incision  into  the  bitten  area,  pouring  into  the 
wound  rattlesnake  bile,  and  giving  carbonate  of  ammonium 
internally.  The  poisonous  lizard  (Gila  monster)  can  kill 
small  animals,  but  it  is  not  believed  that  its  bite  would  prove 
fatal  to  man. 

Anthrax  (malignant  pustule,  charbon,  wool-sorters'  dis- 
ease, Milzbrand,  or  splenic  fever)  is  a  term  used  by  some  as 
synonymous  with  ordinary  carbuncle,  but  it  is  not  here  so 
employed.  Anthrax,  as  met  with  in  man,  is  a  disease  con- 
tracted in  some  manner  from  an  animal  with  splenic  fever. 
It  may  be  contracted  by  working  around  diseased  animals, 
by  handling  or  tanning  their  hides,  by  sorting  their  hair  or 
wool ;  it  may  be  conveyed  by  eating  infected  meat  or  by 
drinking  infected  milk.  Flies  may  carry  the  poison.  Inhala- 
tion of  poisoned  dust  may  infect  the  lungs.  Catgut  ligatures 
may  be  contaminated  and  carry  the  poison.     Many  attempts, 

1  Charters  James  Symonds,  in  Heath'' s  Dictionary  of  Practical  Surgery. 
'^  Medical  Record,  Sept.  5,  1896. 


CONTUSIONS  AND    WOUNDS.  1 79 

not  altogether  satisfactory,  have  been  made  to  render  ani- 
mals immune  (Pasteur,  Wooldridge,  Hankin).  Certain  or- 
ganisms are  antagonistic  to  anthrax  (the  streptococcus  of 
erysipelas,  the  pneumococcus,  the  micrococcus  prodigiosus, 
and  the  bacillus  pyocyaneus). 

Forms  of  Anthrax. — There  are  two  forms  of  the  disease 
— external  and  internal.  Internal  anthrax  may  be  intestinal 
from  eating  diseased  meat  or  pulmonary  from  inhalation  of 
poisoned  dust.  External  anthrax  may  be  anthrax  carbuncle 
or  anthrax  edema.  The  external  form  appears  in  from  three 
to  six  days  after  inoculation,  and  presents  a  papule  with  a  red 
base ;  the  papule  becomes  a  vesicle  which  contains  bloody 
serum ;  the  vesicle  bursts  and  dries,  the  base  of  it  swells  and 
enlarges,  other  vesicles  appear  in  circles  around  it,  and  there 
is  developed  an  "  anthrax  carbuncle,"  which  shows  a  black 
or  purple  elevation  with  a  central  depression  surrounded  by 
one  or  more  rings  of  vesicles.  Pain  is  trivial.  Lymphatic 
enlargements  occur.  Within  forty-eight  hours  after  the  pus- 
tule begins  organisms  appear  in  the  blood.  In  loose  con- 
nective tissue  the  lesion  may  be  anthrax  edema,  a  spreading 
livid  edema  followed  by  blebs  and  even  by  gangrene.  The 
constitutional  symptoms  may  rapidly  follow  the  local  lesion, 
but  may  be  deferred  for  a  week  or  more.  The  patient  feels 
depressed,  has  obscure  aches  and  pains,  and  is  feverish,  but 
usually  keeps  about  for  a  short  period.  After  a  time  he  is 
apt  to  develop  rigors,  high  irregular  fever,  sweats,  acute  fugi- 
tive pains,  diarrhea,  delirium,  typhoid  exhaustion,  dyspnea, 
cough,  and  cyanosis.  The  local  carbuncle  of  anthrax  is  dis- 
tinguished from  ordinary  carbuncle  by  the  central  depres- 
sion, the  adherent  eschar,  the  absence  of  tenderness,  and  the 
absence  of  suppuration  of  the  first,  as  contrasted  with  the 
elevated  centre,  the  multiple  foci  of  suppuration  and  slough- 
ing, and  the  acute  pain  of  the  second.  Anthrax  edema  dif- 
fers from  cellulitis  in  the  absence  of  all  tendency  to  form 
pus,  and  from  malignant  edema  by  the  greater  tendency  of 
the  latter  to  result  in  gangrene.  If  anthrax  has  a  visible 
lesion  and  the  constitutional  symptoms  are  slight  or  absent, 
the  chance  of  cure  is  good. 

Treatment. — If  a  person  is  wounded  by  an  object  sus- 
pected of  carrjang  the  infection,  cauterize  the  wound  with 
the  hot  iron.  A  sufferer  from  anthrax  must  be  isolated  in  a 
well-ventilated  room.  All  dressings  are  to  be  burnt,  all 
discharges  asepticized,  and  after  the  removal  of  the  patient 
the  bed-clothes  are  burnt  and  the  room  disinfected.  A 
malignant  pustule  should  be  entirely  excised,  and  the  wound 


l8o  MODERN  SURGERY. 

mopped  out  with  pure  carbolic  acid  or  burnt  with  the  hot 
iron,  and  afterward  dressed  with  wet  bichlorid-of-mercury 
gauze  which  is  covered  with  an  ice-bag.  Excision  should 
be  practised  even  when  glands  are  enlarged,  but  it  will  prove 
ineffectual  if  organisms  are  present  in  the  blood.  When 
excision  cannot  be  performed  make  crucial  incisions  through 
the  lesion,  mop  out  with  pure  carbolic  acid,  and  inject  around 
and  in  the  pustule  carbolic  acid  (i  :  lo)  every  six  hours  until 
the  disease  abates  or  toxic  symptoms  appear.  The  adher- 
ent eschar  is  subsequently  removed  by  antiseptic  poultices. 
Davaine  advised  the  following  plan :  Inject  the  pustule  and 
the  tissues  about  it  at  many  points  every  eight  or  ten  hours 
with  I  part  of  tincture  of  iodin  diluted  with  2  parts  of  water 
or  with  a  lo  per  cent,  solution  of  carbolic  acid,  or  with  a  -^-^ 
per  cent,  solution  of  corrosive  sublimate.  Dress  with  wet 
antiseptic  gauze  and  apply  an  ice-bag.  Inflamed  lymphatic 
vessels  and  glands  should  be  painted  with  iodin  and  smeared 
with  ichthyol.  Constitutional  treatment  is  sustaining  and 
stimulating.  Maffucci  gives  carbolic  acid  internally,  and 
also  uses  it  externally.  Davies-Colley  uses  ipecac  locally 
and  gives  large  doses  by  the  mouth.  Pulmonary  anthrax 
and  intestinal  anthrax  are  always  fatal.  The  treatment  is 
symptomatic. 

Hydrophobia,  Rabies,  or  I^yssa. — Hydrophobia  is  a 
spasmodic  and  paralytic  disease  due  to  infection  through  a 
wound  with  the  virus  from  a  rabid  animal.  The  animal 
may  be  a  dog,  a  cat,  a  wolf,  a  fox,  or  a  horse.  Roux  esti- 
mates that  about  14  per  cent,  of  the  people  bitten  by  mad 
animals  develop  the  disease.  If  the  bite  is  on  an  exposed 
part,  it  is  far  more  apt  to  cause  rabies  than  if  the  teeth  pass 
through  clothing.  Hydrophobia  is  almost  invariably  fatal. 
The  saliva  is  the  usual  vehicle  of  contagion,  but  other  fluids 
and  tissues  contain  the  virus,  especially  the  brain  and  cord. 

Symptoms. — The  period  of  incubation  of  hydrophobia  is 
from  a  few  weeks  to  two  years.  The  initial  symptoms  are 
mental  depression,  anxiety,  headache,  malaise,  and  often  pain 
or  even  congestion  in  the  cicatrix,  which  symptoms  are 
quickly  followed  by  a  general  hyperesthesia,  pharyngeal 
spasms,  dyspnea  from  laryngeal  spasms,  and  constant  attempts 
to  expectorate  thick  mucus  which  forms  because  of  congestion 
of  the  air-passages.  Attempts  at  swallowing,  as  well  as  lights 
and  noises,  tend  to  bring  on  spasms,  hence  the  fear  of  liquids 
(there  is  spasm  from  attempts  at  swallowing  or  from  thinking 
of  the  act).  The  entire  body  may  be  thrown  into  clonic  spasms, 
but  there  is  no  tonic  spasm.     The  mind  is  usually  clear, 


CONTUSIONS  AND    WOUNDS.  l8l 

although  during  the  periods  of  excitement  there  may  be 
maniacal  furor  with  hallucinations  which  pass  away  in  the 
stage  of  relaxation.  The  temperature  is  moderately  elevated 
(iOi°  to  103°  or  higher).  This  spasmodic  stage  lasts  from 
one  to  three  days,  and  the  patient  may  die  during  this  period 
from  exhaustion  or  from  asphyxia.  If  he  lives  through  this 
period,  the  convulsions  gradually  cease,  the  power  of  swal- 
lowing returns,  and  the  patient  succumbs  to  exhaustion  in 
less  than  twenty-four  hours,  or  he  develops  ascending  paral- 
ysis which  soon  causes  cardiac  and  respiratory  failure. 

In  hydrophobia  death  is  practically  inevitable.  Almost 
all  cases  in  which  it  is  alleged  that  recovery  ensued  were  not 
true  hydrophobia,  but  hysteria.  Wood  says  that  in  hysteria, 
especially  among  boys,  "  beast-mimicry  "  is  common,  the  suf- 
ferer snarling  like  a  dog,  and  in  the  form  known  as  "spurious 
hydrophobia,"  in  which  there  may  or  may  not  be  convulsion, 
there  are  a  dread  of  water,  emotional  excitement,  snarling,  and 
attempts  to  bite  the  bystanders  (in  genuine  hydrophobia  no 
attempts  are  made  to  bite,  and  sounds  are  uttered  like  those 
made  by  a  dog). 

Lyssa  is  separated  from  lockjaw  by  the  spasms  of  the 
larynx  and  the  absence  of  tonic  spasms  in  the  former,  as 
contrasted  with  the  spasms  of  muscles  of  mastication  and 
the  tonic  spasms  with  clonic  exacerbations  of  lockjaw. 

Treatment. — When  a  person  is  bitten  by  a  supposed  rabid 
animal,  apply  constriction  above  the  wound  if  possible,  excise, 
and  burn  with  the  hot  iron.  Send  the  patient  to  a  Pasteur 
institute  at  once,  that  he  may  be  given  preventive  inocula- 
tions of  an  emulsion  made  from  the  dried  spinal  cords  of 
hydrophobic  rabbits  (attenuated  virus).  Pasteur  discovered 
the  following  remarkable  facts  :  If  the  virus  of  a  rabid  dog 
(street  rabies)  be  placed  beneath  the  dura  of  another  dog,  it 
always  causes  hydrophobia  in  from  sixteen  to  twenty  days, 
and  invariably  causes  death.  If  the  virus  is  passed  through 
a  series  of  rabbits  it  gets  stronger  (laboratory  virus),  and  if  in- 
serted beneath  the  dura  of  a  dog,  it  causes  the  disease  in  from 
five  to  six  days,  and  kills  in  four  or  five  days.  The  virus  can 
be  attenuated  by  passing  through  a  series  of  monkeys  or  by 
keeping.  To  get  attenuated  preparations  in  a  convenient 
form  he  made  emulsions  from  the  cords  of  rabbits  dead  two 
or  three  weeks.  The  emulsion  obtained  from  the  rabbit 
longest  dead  is  the  weakest.  He  injected  a  dog  with  emul- 
sions of  progressively  increasing  strength  and  made  it  im- 
mune to  hydrophobia.  These  emulsions  cause  the  body-cells 
to  develop  antitoxins,  which  are  already  in  the  body  when 


1 82  MODERN  SURGERY. 

the  street  rabies  virus  begins  to  develop.  The  report  of  the 
Parisian  Pasteur  Institute  shows  that  since  its  foundation  there 
has  been  a  mortahty  of  0.5  per  cent.  The  lowest  estimated 
number  of  those  attacked  by  hydrophobia  before  this  method 
was  used  was  5  per  cent,  of  those  bitten,  and  all  attacked 
died ;  hence,  the  Pasteur  treatment  shows  one-twenty-fifth 
of  the  mortality  which  attends  other  preventive  methods. 
The  value  of  this  plan  seems  definitely  established.  Murri, 
of  Bologna,  cured  a  case  of  hydrophobia  by  injecting  emul- 
sions of  cords  of  rabbits  dead  six,  five,  four,  and  three  days 
respectively.  This  remedy  should  be  tried.  In  the  paroxysm 
the  treatment  in  the  past  was  palliative.  If  we  try  only  pal- 
liative methods,  keep  the  patient  in  a  dark,  quiet  room,  re- 
lieve thirst  by  enemata,  saturate  with  morphin,  in  the  parox- 
ysms anesthetize,  empty  the  bowels  by  enemata,  and  attend 
to  the  bladder. 

Glanders,  Farcy,  or  i^quinia. — Glanders  is  an  infec- 
tious eruptive  fever  occurring  in  horses  and  communicable  to 
man.  If  the  nodules  occur  in  a  horse's  nares,  we  call  the 
disease  "  glanders ;"  if  beneath  his  skin,  it  is  termed  "  farcy." 
This  disease  is  due  to  the  bacillus  of  Loffler,  and  is  communi- 
cated to  man  through  an  abraded  surface  or  a  mucous  mem- 
brane (Osier).  The  characteristic  lesions  are  infective  granu- 
lomata,  which  in  the  nose  form  ulcers  and  under  the  skin 
develop  abscesses. 

Acute  and  Chronic  Glanders. — In  acute  glanders  there  is 
septic  inflammation  at  the  point  of  inoculation  ;  nodules  form 
in  the  nose,  and  ulcerate ;  there  is  profuse  nasal  discharge ; 
the  glands  of  the  neck  enlarge ;  there  are  fever  and  an  erup- 
tion like  small-pox  on  the  face  and  about  the  joints  (Osier) 
and  severe  muscular  pain.  Acute  glanders  is  always  fatal. 
Chronic  glanders  lasts  for  months,  is  rarely  diagnosticated, 
being  mistaken  for  catarrh,  and  is  often  recovered  from. 
Diagnosis  is  made  by  injecting  a  guinea-pig  .with  the  nasal 
mucus. 

Acute  and  Chronic  Farcy. — Acute  farcy  appears  from  a 
skin-inoculation ;  it  begins  as  an  intense  inflammation,  from 
which  run  out  inflamed  lymphatics  that  present  nodules  or 
"  farcy-buds."  Abscesses  form.  There  are  joint-pain  and 
the  constitutional  symptoms  of  sepsis,  but  no  involvement 
of  the  nares.  Chronic  farcy  may  last  for  months.  In  it 
nodules  occur  upon  the  extremities,  which  nodules  break 
down  into  abscesses  and  eventuate  in  ulcers  resembling 
those  of  tuberculosis. 

Treatment. — In  treating  this  disease  the  point  of  infection 


CONTUSIOiVS  AND    IVOUNDS.  1 83 

is  at  once  to  be  incised  and  cauterized,  dusted  with  iodoform, 
and  dressed  antiseptically.  Enlarged  glands  and  swollen 
lymphatics  are  to  be  painted  with  iodin  and  smeared  with 
ichthyol.  Bandages  are  applied  to  edematous  extremities. 
Ulcers  are  curetted,  touched  with  pure  carbolic  acid,  dusted 
with  iodoform,  and  dressed  antiseptically.  The  nose  is  sprayed 
at  frequent  intervals  with  peroxid  of  hydrogen,  and  is  fre- 
quently syringed  with  sulphurous  acid.  The  mouth  is  rinsed 
repeatedly  with  solutions  of  chlorate  of  potassium.  Open 
the  abscesses,  swab  out  with  pure  carbolic  acid,  and  dress 
antiseptically.  Give  stimulants  and  nourishing  diet.  Morphin 
will  be  necessary  for  the  muscular  pain,  restlessness,  and  in- 
somnia. Digitalis  is  given  to  stimulate  the  circulation  and 
kidney  secretion.  Sulphur  iodid,  arsenite  of  strychnin,  and 
bichlorate  of  potassium  have  been  used.  Diseased  horses 
ought  at  once  to  be  killed  and  their  stalls  tcwn  out  and  puri- 
fied. A  man  with  chronic  glanders  should  be  removed  to 
the  seaside.  The  nasal  passages  should  be  kept  clean ; 
ulcers  must  be  cauterized  and  dressed  with  iodoform  gauze. 
Nutritious  foods,  tonics,  and  stimulants  are  necessary. 

Actinomycosis  is  an  infectious  disorder  characterized  by 
chronic  inflammation,  and  is  due  to  the  presence  in  the  tis- 
sues of  the  actinoniyccs  or  ray-fungus.  This  disease  occurs 
in  cattle  (lumpy  jaw)  and  in  pigs,  and  can  be  transmitted  to 
man,  usually  by  the  food.  At  the  point  of  inoculation  (which 
is  generally  about  the  mouth)  arises  an  infective  granuloma, 
around  which  inflammation  of  connective  tissue  occurs,  sup- 
puration eventually  taking  place.  Inoculation  in  the  mouth 
is  by  way  of  an  abrasion  of  mucous  membrane  or  through 
a  carious  tooth.  Chewing  straw  which  contains  the  fungi  is 
the  most  common  method  of  infection.  The  ray-fungi  may 
pass  into  the  lungs,  causing  pulmonary  actinomycosis ;  into 
the  intestines,  causing  intestinal  actinomycosis  ;  into  the  skin, 
the  bones,  the  subcutaneous  tissues,  the  heart,  the  brain,  the 
liver,  etc.  Actinomycosis  until  very  recently  was  looked 
upon  as  sarcoma. 

Cutaneous  actinomycosis  may  be  secondary  to  a  visceral 
area  of  disease,  may  be  a  purely  local  condition,  or  may  be 
associated  with  some  adjacent  area  of  bone-infection.  The 
gummatous  form  of  the  disease  resembles  a  gummatous 
syphilitic  area,  and  in  it  many  small  purulent  pockets  open 
by  fistulae  (Monestie). 

In  the  anthracoid  there  are  no  distinct  purulent  collections, 
but  many  fistulae  discharge  pus  at  various  points  (Monestie). 

An  area  of  cutaneous  anthrax  is  characterized  by  the  ex- 


184  MODERN  SURGERY. 

istence  of  violet,  blue,  gray,  or  black  maculae,  varying  in 
size  from  that  of  a  pin's  head  to  that  of  a  bean,  the  center 
of  each  macule  being  white  and  containing  a  minute  quantity 
of  pus  (Derville). 

The  pus  of  actinomycosis  contains  many  sulphur-yellow 
bodies,  visible  to  the  naked  eye  and  composed  of  fungi. 
These  bodies  feel  gritty  when  rubbed  between  the  fingers 
because  of  the  presence  of  lime  salts. 

In  actinomycosis  of  bone  the  bone  enlarges  and  becomes 
painful,  the  parts  adjacent  are  infiltrated  and  soften,  pus  forms 
and  reaches  the  surface  through  fistulae,  and  the  skin  is  often 
involved  secondarily. 

In  actinomycosis  the  adjacent  lymphatic  glands  are  not 
involved.  The  diagnosis  must  be  made  from  syphilis,  sar- 
coma, and  tuberculosis.  The  microscopic  examination  of 
the  pus  makes  the  diagnosis. 

Treatment. — Free  excision  if  possible ;  otherwise  incision, 
cauterizing  with  pure  carbolic  acid,  and  packing  with  iodo- 
form gauze.  Give  internally  large  doses  of  iodid  of  potas- 
sium.    This  drug  alone  has  cured  many  cases. 

Wounds  of  Mucous  Membranes. — If  the  surgeon  intends 
to  inflict  a  wound  upon  a  mucous  surface,  he  should  see  to  it 
that  the  patient's  general  condition  is  good.  Thorough  asepsis 
is  impossible,  and  a  good  result  depends  largely  upon  the 
vital  resistance  of  the  tissues.  Before  operating  many  sur- 
geons irrigate  the  part  frequently  with  boric  acid,  a  proceed- 
ing of  questionable  value.  When  ready  to  sew  up,  be  sure 
that  all  irritant  fluids  are  removed  from  the  wound  (saliva 
in  the  mouth,  etc.).  Cleanse  the  wound  with  hot  normal  salt 
solution.  The  stitches  must  include  submucous  tissue  as 
well  as  the  mucous  membrane,  and  consist  of  silver  wire,  silk, 
or  silkworm  gut.  After  sewing  up,  wash  often  with  salt  so- 
lution, and  follow  it  by  insufflation  of  iodoform. 

In  accidental  wounds  irrigate  with  salt  solution,  dust  with 
iodoform,  and  close  as  directed  above.  Corrosive  sublimate 
is  so  irritant  that  it  does  only  harm  when  appHed  to  a  mu- 
cous membrane. 


XVI.    SYPHILIS. 

Definition. — Syphilis  is  a  chronic  infectious,  and  some- 
times hereditary,  constitutional  disease.  Its  first  lesion  is  an 
infecting  area  or  chancre,  which  is  followed  by  lymphatic  en- 
largements, eruptions  upon  the  skin  and  mucous  membranes, 
affections  of  the  appendages  of  the   skin   (hair  and  nails). 


SYPHILIS.  185 

"  chronic  inflammation  and  infiltration  of  the  cellulo-vascu- 
lar  tissue,  bones,  and  periosteum  "  (White),  and,  later,  often 
by  gummata.  This  disease  is  probably  due  to  a  microbe, 
but  Lustgarten's  bacillus  has  not  been  proved  to  be  the  one. 
One  fact  against  its  being  the  cause  is  its  presence  in  the 
non-contagious  late  gummata.  White  quotes  Fenger  in  his 
assumption  that  syphilitic  fever  is  due  to  absorption  of 
toxins  ;  that  the  eruptions  of  skin  and  mucous  membranes 
in  the  secondary  stage  arise  from  local  deposit  and  multipli- 
cation of  the  virus ;  that  many  secondary  symptoms  result 
from  nutritive  derangement  caused  by  tissue-products  passing 
into  the  circulation  ;  that  the  virus  exists  in  the  body  after 
the  cessation  of  secondary  symptoms  ;  and  that  it  may  die 
out  or  may  awaken  into  activity,  producing  "  reminders." 

During  the  primary  and  secondary  stages  fresh  poison  can- 
not infect,  and  this  is  true  for  a  time  after  the  disappearance 
of  secondary  symptoms.  Immunity  in  the  primary  stage  is 
due  to  products  absorbed  from  the  infected  area.  Colles's 
immunity  is  that  acquired  by  mothers  who  have  borne  syph- 
ilitic children,  but  who  themselves  show  no  sign  of  the  dis- 
ease. Profeta's  immunity  is  the  immunity  against  infection 
possessed  by  many  healthy  children  born  of  syphilitic  par- 
ents. Tertiary  syphilitic  lesions  are  not  due  to  the  poison 
of  syphilis,  but  to  tissue-products  from  the  action  of  that 
poison,  or  to  nutritive  failure  as  a  consequence  of  the  disease. 
Tertiary  syphilis  is  not  transmissible,  but  it  secures  immunity. 

Transmission  of  Syphilis. — This  disease  can  be  trans- 
mitted— (i)  by  contact  with  the  tissue-elements  or  virus — 
acquired  syphilis  ;  and  (2)  by  hereditary  transmission — hered- 
itary syphilis.  The  poison  cannot  enter  through  an  intact 
epidermis  or  epithelial  layer,  and  abrasion  or  solution  of  con- 
tinuity is  requisite  for  infection.  Syphilis  is  usually,  but  not 
always,  a  venereal  disease.  It  may  be  caught  by  infection 
of  the  genitals  during  coition,  by  infection  of  the  tongue  or 
lips  in  kissing,  by  smoking  poisoned  pipes,  by  drinking  out 
of  infected  vessels,  or  by  beastly  practices.  The  initial  lesion 
of  syphilis  may  be  found  on  the  finger,  penis,  eyelid,  lip, 
tongue,  cheek,  palate,  anus,  nipple,  etc.  A  person  may  be 
a  host  for  syphilis,  carry  it,  give  it  to  another,  and  yet  escape 
it  himself  (a  surgeon  may  carry  it  under  his  nails,  and  a 
woman  may  have  it  lodged  in  her  vagina).  Syphilis  can  be 
transmitted  by  vaccination  with  human  lymph  which  contains 
the  pus  of  a  syphilitic  eruption  or  the  blood  of  a  syphilitic 
person.  Vaccine  lymph,  even  after  passage  through  a  per- 
son with  pox,  will  not  convey  syphilis  if  it  is  free  from  blood 


1 86  MODERN  SURGERY. 

and  the  pus  of  specific  lesions ;  it  is  not  the  lymph  that 
poisons,  but  some  other  substance  which  the  lymph  may 
carry. 

Syphilitic  Stages. — Syphilis  was  divided  by  Ricord 
into  three  stages :  (i)  the  primary  stage — chancre  and  indo- 
lent bubo ;  (2)  the  secondary  stage — disease  of  the  upper 
layer  of  the  skin  and  mucous  membranes ;  and  (3)  the 
tertiary  stage — affections  of  connective  tissues,  bones,  fibrous 
and  serous  membranes,  and  parenchymatous  organs.  This 
division,  which  is  useful  clinically,  is  still  largely  employed, 
but  it  is  not  so  sharp  and  distinct  as  was  believed  by  Ricord ; 
it  is  only  artificial.  For  instance,  ozena  may  develop  during 
a  secondary  eruption,  and  bone  disease  may  appear  early  in 
the  case. 

Syphilitic  Periods. — White  divides  the  pox  into  the 
following  periods:  (i)  period  oi  primary  incubation — the 
time  between  exposure  and  the  appearance  of  the  chancre : 
from  ten  to  ninety  days,  the  average  being  three  weeks ;  (2) 
period  of  primary  symptoms — chancre  and  bubo  of  adjacent 
lymph-glands  ;  (3)  period  of  secondary  incubation — the  time 
between  the  appearance  of  the  chancre  and  the  advent  of 
secondary  symptoms :  about  six  weeks  as  a  rule ;  (4)  period 
of  secondary  symptoms — lasting  from  one  to  three  years ;  (5) 
intermediate  period — there  may  be  no  symptoms  or  there  may 
be  light  symptoms  which  are  less  symmetrical  and  more  gen- 
eral than  those  of  the  secondary  period :  it  lasts  from  two  to 
four  years,  and  ends  in  recovery  or  tertiary  syphilis ;  and  (6) 
period  of  tertiary  symptoms — indefinite  in  duration.  The 
fifth  and  sixth  periods  may  never  occur,  the  disease  being 
cured. 

Primary  Syphilis. — The  primary  stage  comprises  the 
chancre  or  infecting  sore  and  bubo.  A  chancre  or  initial 
lesion  is  an  infective  granuloma  resulting  from  the  poison 
of  syphilis.  A  chancre  may  be  derived  from  the  discharges 
of  another  chancre,  from  the  secretion  of  mucous  patches 
and  moist  papules,  from  syphilitic  blood,  or  from  the  pus  or 
secretion  of  any  secondary  lesion.  Tertiary  lesions  cannot 
cause  chancre.  It  appears  at  the  point  of  inoculation,  and 
is  the  first  lesion  of  the  disease.  During  the  three  weeks 
or  more  requisite  to  develop  a  chancre  the  poison  is  con- 
tinuously entering  the  system,  and  when  the  chancre  devel- 
ops the  system  already  contains  a  large  amount  of  poison. 
A  chancre  is  not  a  local  lesion  from  which  syphilis  springs, 
but  is  a  local  manifestation  of  an  existing  constitutional  dis- 
ease, hence  excision  is  entirely  useless.     If  we  take  the  dis- 


SYPHILIS.  187 

charge  of  a  chancre  and  insert  it  at  some  indifferent  point 
into  the  person  from  whom  we  took  it,  a  new  chancre  will 
not  be  formed,  because  he  already  has  syphilis.  Auto- 
inoculation  of  the  discharge  of  an  irritated  chancre  can  cause 
a  non-indtiratcd  sore.  If  we  insert  the  poison  into  another 
person,  a  chancre  is  formed.  Hence  we  say  that  primary 
syphilis  is  not  auto-inoculable,  but  is  hetero-inoculable.  A 
soft  sore  can  be  produced  in  lower  animals  by  inoculation, 
but  a  hard  sore  cannot.  Some  observers,  notably  Kaposi, 
of  Vienna,  advocate  the  unity  theory.  This  theory  main- 
tains that  both  hard  and  soft  sores  are  due  to  the  same 
virus,  the  infective  power  of  the  soft  chancre  simply  being 
less  than  that  of  the  hard,  the  possibility  of  constitutional 
infection  depending,  not  upon  differences  in  the  poison,  but 
rather  upon  differences  in  the  soil  and  in  the  local  processes. 
The  unicists  advocate  excision  of  chancres,  soft  or  hard,  to 
prevent,  if  possible,  constitutional  involvement.  Most  syph- 
ilographers  believe  in  the  duality  theory,  which  we  have 
previously  set  forth.  This  theory  took  origin  from  the  clas- 
sical investigations  of  Bassereau  and  RoUet.  The  duality 
theory  maintains  that  the  soft  sore  is  caused  by  a  different 
poison  than  originates  the  hard  sore,  and  that  a  true  soft 
sore  never  infects  the  system.^ 

Initial  I^esions. — An  initial  lesion,  hard  chancre,  or 
infecting  sore  never  appears  until  at  least  ten  days  after 
exposure ;  it  may  not  appear  for  many  weeks,  but  it  usually 
arises  in  about  twenty-five  days.  There  are  three  chief 
forms  of  initial  lesion  :  (i)  a  purple  patch  exposed  by  peeling 
epidermis,  without  induration  and  ulceration — a  rare  form  ; 
(2)  an  indurated  area  under  the  epidermis,  without  ulceration 
— a  very  common  form ;  and  (3)  a  round,  indurated,  carti- 
laginous area  with  an  elevated  edge,  which  ulcerates,  expos- 
ing a  velvety  surface  looking  like  raw  ham  ;  it  bleeds  easily, 
it  rarely  suppurates,  it  does  not  spread,  and  the  discharge 
is  thin  and  watery.  This  is  the  "  Hunterian  chancre,"  which 
is  rarer  than  the  second  variety,  but  commoner  than  the 
first,  and  which  ulcerates  because  of  dirt,  caustic  applications, 
or  friction. 

A  chancre  is  rarely  multiple,  but  if  it  is  so,  all  the  sores 
appear  together  as  a  result  of  the  primary  inoculation  :  they 
do  not  follow  one  another  because  of  auto-infection.  A 
hard  sore  does  not  suppurate  unless  irritated  by  caustics, 
friction,  or    dirt,  or    unless    there    be   mixed   infection   with 

^  For  a  full  discussion  of  these  points  see  the  writings  of  Fournier,  Alfred 
Cooper,  and  \'on  Zeissl,  and  especially  the  great  work  of  Taylor. 


1 88  MODERN  SURGERY. 

chancroid ;  its  nature  is  not  to  suppurate.  The  hardness 
may  affect  only  the  base  and  margins  of  an  ulcer  or  it  may 
affect  considerable  areas,  but  it  has  well-defined  margins  and 
feels  hke  cartilage  encapsuled,  so  that  it  can  be  picked  up 
in  the  fingers.  This  hardness  or  sclerosis  is  due  to  gradual 
inflammatory  exudation  into  "  the  tissues  at  the  base  of  the 
ulcer  and  to  growth  of  the  nodule  "  (Von  Zeissl).  It  feels 
distinct  from  the  surrounding  tissues,  like  a  foreign  body 
lying  in  the  part.  A  chancre  untreated  may  last  many 
months.  The  induration  usually  disappears  soon  after  the 
appearance  of  secondary  symptoms.  A  copper-colored  spot 
remains,  and  does  not  disappear  until  the  disease  is  cured. 
An  induration  may  again  appear  before  the  outburst  of  some 
distant  lesion. 

Mixed  Infection  of  Chancre  and  Chancroid. — Von 
Zeissl  says :  "  If  syphilitic  contagion  is  mixed  with  pus,  a 
chancre  begins  as  a  circumscribed  area  of  hyperemia  and 
swelling,  which  undergoes  ulceration,  and  does  not  develop 
hardness  for  a  period  of  from  ten  days  to  several  weeks, 
and  may  develop  a  nodule  after  the  first  ulcer  has  entirely 
healed."  We  see  this  condition  when  mixed  infection  occurs, 
the  chancroid  poison  being  quick,  and  the  syphilitic  poison 
being  slow,  to  act.  If  chancroid  poison  is  deposited  some 
time  after  the  syphilitic  poison  has  been  absorbed,  the  indu- 
ration may  appear  in  a  few  days  after  the  chancroid  begins. 
A  soft  chancre  may  appear  upon  an  existing  syphilitic  nodule 
and  may  eat  out  the  induration. 

Diag-nosis  of  Chancre. — We  must  separate  a  chancre 
from  a  chancroid  and  from  ulcerated  herpes.  A  chancroid 
appears  in  from  two  to  five  days  after  contagion  (always  less 
than  ten  days) ;  it  may  be  multiple  from  the  start,  but,  even 
if  beginning  as  one  sore,  other  sores  appear  by  auto-inocu- 
lation ;  it  begins  as  a  pustule,  which  bursts  and  exposes  an 
ulcer ;  this  ulcer  is  circular,  has  thin,  sharp-cut,  or  undermined 
edges,  a  sloughy,  non-granulating  base,  and  a  thin,  purulent, 
offensive  discharge  which  is  both  auto-  and  hetero-inocu- 
lable.  These  soft  sores  have  no  true  sclerotic  area,  do  not 
bleed,  produce  no  constitutional  symptoms,  and  are  apt  to 
be  followed  by  acute  inflammatory  buboes  which  tend  to 
suppurate.  A  chancroid  causes  pain,  and  the  original  ulcer 
enlarges  greatly.  A  chancre  appears  in  about  twenty-five 
days  after  inoculation  (never  before  ten  days) ;  it  is  generally 
single,  but  if  multiple  sores  exist,  they  all  appear  together, 
for  their  discharge  is  not  auto-inoculable ;  if  the  sore  is  not 
irritated,  an  auto-inoculation  of  the  products  of  an  irritated 


SYPHILIS.  189 

chancre  can  at  most  produce  only  a  soft  purulent  ulcer. 
It  begins  as  an  excoriation  or  as  a  nodule ;  if  an  ulcer  forms, 
its  base  is  covered  with  granulations  and  it  is  red  and 
smooth ;  its  discharge  is  thin  and  scanty  and  not  offensive ; 
its  edges  are  thick  and  sloping ;  it  is  surrounded  by  an  area 
of  induration,  and  bleeds  when  touched ;  it  is  followed  by 
secondary  s}-mptoms,  and  there  appear  about  the  same  time 
with  it  indolent  multiple  enlargements  of  the  adjacent  glands, 
which  rarely  suppurate.  A  chancre  causes  little  pain,  and  after  it 
has  existed  for  a  few  days  rarely  shows  any  tendency  to  spread. 
Herpetic  ulceration  has  no  period  of  incubation ;  it  may 
follow  fever,  but  usually  arises  from  friction  or  the  irritation 
of  dirt  or  acrid  discharges.  It  appears  as  a  group  of  vesi- 
cles, all  of  which  may  dr}'  up,  or  some  may  dry  up  and 
others  ulcerate,  or  they  may  run  together  and  ulcerate.  The 
edges  of  a  herpetic  ulcer  are  in  "  segments  of  small  circles  " 
(White) ;  the  ulcer  is  superficial,  has  but  little  discharge,  and 
does  not  have  much  tendency  to  spread ;  it  has  no  indura- 
tion ;  it  is  painful ;  it  has  no  bubo  unless  suppuration  is 
extensive,  and  there  is  no  constitutional  involvement.  A 
urethral  chancre  appears  after  the  usual  period  of  incubation  ; 
it  is  situated  near  the  meatus,  one  lip  of  which  is  usually 
indurated ;  the  discharge  is  slight,  often  bloody,  and  never 
purulent ;  indurated  multiple  buboes  arise ;  the  sore  can  be 
seen,  and  constitutional  symptoms  follow  (White).  A  chan- 
cre may  be  mistaken  for  cancer  of  the  tongue.  "A  chancre 
of  this  region  is  brownish-red,  a  cancer  being  bright  red. 
A  chancre  is  soft  in  the  center ;  .a  cancer  presents  uniformity 
of  induration.  A  chancre  has  a  thin,  purulent  discharge, 
free  from  blood ;  a  cancer  has  a  non-purulent,  bloody  dis- 
charge. A  chancre  is  followed  by  indolent  lymphatic  en- 
largements under  the  jaw ;  a  cancer  is  followed  by  painful 
enlargements."  A  cancer  is  slower  in  evolution,  is  not  fol- 
lowed by  constitutional  symptoms,  and  the  lymphatic  en- 
largements are  much  later  in  appearing  than  in  chancre.  A 
chancre  can  be  attacked  by  phagedena,  a  very  destructive 
form  of  ulceration  which  was  at  one  time  common,  but  at 
the  present  day  is  rare.  The  ulceration  often  spreads  on  all 
sides  and  also  deeply  into  the  tissues.  In  some  cases  it 
spreads  in  only  one  direction  (serpiginous  ulceration),  in 
some  cases  sloughing  occurs.  Phagedena  occurs  only  in 
the  debilitated  (anemic,  drunkards,  strumous  subjects,  suf- 
ferers from  diabetes,  Bright's  disease,  etc. ;  sali\'ation  can 
cause  it).  The  phagedenic  ulcer  is  irregular,  with  congested 
and  edematous  edges,  and  a  foul,  sloughy  floor. 


190  MODERN  SURGERY. 

Syphilitic  Bubo. — In  syphilitic  bubo  anatomically  related 
lymphatic  glands  enlarge  about  the  same  time  as  induration 
of  the  initial  lesion  begins.  In  the  very  beginning  these 
glands  may  be  a  little  painful,  but  they  soon  cease  to  be  so. 
These  enlargements  are  called  "  indolent  buboes  ;"  they  may 
be  as  small  as  peas  or  as  large  as  walnuts,  are  freely  movable, 
and  very  rarely  suppurate.  The  lesion  of  these  glands  is 
hyperplasia  of  all  the  gland-elements  and  of  their  capsules, 
due  to  absorption  of  the  virus.  If  a  man  is  strumous,  the 
bubo  is  apt  to  become  enormous,  lobulated,  and  persistent. 
If  the  chancre  appears  on  the  penis,  the  superficial  inguinal 
and  femoral  glands  enlarge,  usually  on  the  same  side  of  the 
body  as  the  sore;  if  the  sore  is  on  the  frenum,  both  groins 
are  involved.  If  a  chancre  appears  on  the  lip  or  tongue,  the 
bubo  is  beneath  the  jaw.  These  buboes  may  remain  for  many 
months  ;  they  do  not  suppurate  unless  the  sore  suppurates  or 
unless  the  patient  is  of  the  tuberculous  type ;  and  they  finally 
disappear  by  absorption  or  fatty  degeneration.  About  six 
weeks  after  buboes  have  formed  in  the  glands  related  to  the 
lesion,  all  the  lymphatics  of  the  body  enlarge.  General 
lymphatic  involvement  arises  about  the  same  time  as  the 
secondary  eruption.  The  enlargement  of  the  post-cervical 
and  epitrochlear  glands  is  diagnostically  important.  These 
glandular  enlargements  persist  until  after  the  eruptions  have 
disappeared. 

The  bubo  of  syphilis  is  always  present,  while  the  bubo 
exists  in  only  one-third  of  the  chancroid  cases.  The  bubo 
of  syphilis  is  multiple,  consisting  of  a  chain  of  movable  glands 
(the  glandulae  Pleiades  of  Ricord) ;  the  bubo  of  chancroid  is 
one  inflamed  and  immovable  mass.  The  bubo  of  syphilis  is 
indurated,  painless,  small,  and  slow  in  growth ;  the  bubo  of 
chancroid  shows  inflammatory  hardness,  is  painful,  large,  and 
rapid  in  growth  ;  the  first  rarely  suppurates,  the  second  often 
does.  The  skin  over  a  syphilitic  bubo  is  normal ;  that  over 
a  chancroidal  bubo  is  red  and  adherent.  A  syphilitic  bubo 
is  not  cured  by  local  treatment,  but  is  cured  by  the  internal 
use  of  mercuiy  and  is  followed  by  secondar}^  symptoms.  A 
chancroidal  bubo  requires  local  treatment,  is  not  cured  by 
mercury,  and  is  not  followed  by  secondaries.  Herpes,  balan- 
itis, and  gonorrhea  rarely  cause  bubo,  but  when  they  do  the 
bubo  in  each  case  is  similar  to  that  caused  by  chancroid.  A 
positive  diagnosis  of  syphilis  can  be  made  when  an  indurated 
sore  is  followed  by  multiple  indolent  buboes  in  the  groin  and 
by  enlargement  of  distant  glands. 

General  Syphilis. — As  the  general  lymphatic  enlarge- 


SYPHILIS.  191 

ment  becomes  manifest  there  is  apt  to  appear  a  group  of 
symptoms  known  as  "  syphilitic  fever."  The  patient  usually 
thinks  he  has  a  bad  cold  and  is  feverish  and  restless  ;  he 
complains  of  sleeplessness  and  anorexia  ;  his  face  is  pale  ;  he 
has  intermitting  rheumatoid  pains  in  the  joints  and  muscles, 
especially  of  the  shoulders,  arms,  chest,  and  back,  which  pains 
change  their  location  constantly  and  prevent  sleep ;  night- 
sweats  occur,  and  the  pulse  is  quite  frequent.  This  fever 
usually  reaches  its  height  in  forty-eight  hours,  and  falls  as 
the  eruption  develops.  Syphilitic  fever  does  not  always  arise. 
It  may  reappear  during  the  progress  of  the  disease. 

Secondary  Syphilis. — The  phenomena  of  secondary 
syphilis  arise  from  poisoned  blood.  Fenger  states  that  the 
poison  is  present  in  the  blood  during  outbreaks,  but  not  dur- 
ing the  quiescent  periods  between  outbreaks.  Secondary 
syphilis  is  characterized  by  plastic  inflammation,  by  the  for- 
mation of  fibrous  tissue,  and  by  thickening  of  tissue.  Super- 
ficial ulcerations  may  occur.  Structural  overgrowths  appear 
(warts). 

Syphilitic  Skin  Diseases. — Syphilodcrmata{?,y^^\vL\\^^e^), 
due  to  circumscribed  inflammation,  may  be  dry  or  purulent. 
There  is  no  one  eruption  characteristic  of  syphilis.  This  dis- 
ease may  counterfeit  any  skin  disease,  but  it  is  an  imitation 
which  is  not  perfect  and  is  never  a  counterpart.  Syphilitic 
eruptions  are  often  circumscribed ;  they  terminate  suddenly 
at  their  edges,  and  do  not  gradually  shade  into  the  sound 
skin.  In  color  they  are  apt  to  be  brownish-red,  like  tarnished 
copper;  especially  is  this  the  case  in  late  syphilides.  Hutch- 
inson cautions  us  to  remember  that  an  ordinary  non-specific 
eruption  may  be  copper-colored,  especially  in  people  with 
dark  complexion  and  when  it  occurs  on  the  legs.  Eruptions 
are  apt  to  leave  a  brownish  stain.  Early  syphilitic  eruptions 
are  symmetrical.  Syphilitic  eruptions  have  an  affection  for 
particular  regions,  such  as  the  forehead,  the  abdomen  and 
chest,  the  neck  and  scalp,  about  the  lips  and  the  alae  of  the 
nose,  the  navel,  anus,  groins,  between  the  toes,  and  upon  the 
palms  and  soles.  Early  secondary  eruptions  rarely  appear 
on  the  face  or  hands.  Specific  eruptions  are  polymorphous, 
various  forms  of  eruption  being  often  present  at  the  same 
time,  so  that  roseola  is  seen  here,  papules  there,  etc.  These 
syphilides  do  not  cause  as  much  itching  as  do  non-spe- 
cific eruptions,  except  when  they  occur  about  the  anus  or 
between  the  toes.  They  tend  to  an  arrangement  in  curved 
lines. 

Forms  of  Eruption. — The  chief  forms  of  eruption  are 


192  MODERN  SURGERY. 

(i)  erythema,  (2)  papular  syphilides,  (3)  pustular  syphilides, 
and  (4)  tubercular  syphilides.  Besides  these  eruptions  pig- 
mentation may  occur  (pigmentary  syphilide),  and  blood  may 
extravasate  (purpuric  syphilide). 

Prince  A.  Morrow  does  not  believe  in  erecting  the  vesicu- 
lar syphilide  into  a  special  group.  He  tells  us  that  vesicles 
sometimes  form  on  erythemato-papular  lesions,  but  their 
presence  is  an  accident  and  not  a  regular  phenomenon.  So, 
too,  the  bullous  syphihde  is  a  rare  accident  in  a  case,  and 
even  when  it  occurs  soon  becomes  pustular.  The  pem- 
phigoid syphilide  is  found  almost  exclusively  in  hereditary 
disease.^ 

I.  Erythema  {inaculce,  roseola,  or  spots)  presents  round, 
circumscribed,  red,  hyperemic  spots,  about  one-eighth  of  an 
inch  in  diameter,  whose  color  does  not  entirely  disappear  on 
pressure  in  an  old  eruption  but  does  in  a  recent  one.  In  the 
papular  form  of  erythema  the  spots  are  a  little  elevated.  It 
is  rare  upon  the  face  and  dorsum  of  the  hands  and  feet.  It 
attacks  especially  the  chest  and  belly,  but  appears  often  on 
the  forehead,  the  bend  of  the  elbow,  and  the  inner  portion  of 
the  thigh,  the  neck,  and  the  flexor  surface  of  the  forearms  and 
arms.  Usually  erythema  follows  syphilitic  fever,  about  six 
weeks  after  the  chancre  appears,  and  the  number  and  dis- 
tinctness of  these  spots  are  in  proportion  to  the  violence  of 
the  fever.  Absent  or  slight  fever  means  few  and  transient 
spots.  In  rare  cases  the  disease  is  very  transitory,  lasting 
but  a  few  hours,  but  it  usually  lasts  for  several  weeks  if  un- 
treated. It  may  pass  away  or  may  be  converted  into  a  papu- 
lar eruption.  Mercury  will  cause  it  to  disappear  in  a  couple 
of  weeks.  In  examining  for  this  form  of  eruption  in  a  doubt- 
ful case,  let  cold  air  blow  upon  the  chest  and  belly  (Hearn) ; 
this  blanches  the  sound  skin  and  makes  clear  any  discolora- 
tion. No  desquamation  attends  this  eruption.  A  brownish 
stain  remains  for  a  variable  time  after  the  eruption  fades. 
Erythema  means,  as  a  rule,  a  mild  and  curable  attack.  Mac- 
ulae may  be  combined  with  the  next  form,  constituting  a 
maculo-papular  eruption. 

The  maculo-papular  syphilides  are  evolved  from  the  macu- 
lar syphilides.  They  are  slightly  elevated,  are  situated  upon 
a  hyperemic  base,  and  the  summit  of  some  of  them  may  un- 
dergo slight  desquamation.  A  roseolar  area  may  show  one 
or  several  of  these  macular  papules.  They  are  apt  to  arrange 
themselves  in  segments  of  a  circle,  and  are  symmetrically 
distributed.     This  eruption  usually  appears  early,  but  may 

1  Morrow's  System  of  Geniio-urinary  Diseases,  Syphilology,  and  Dermatology. 


SYPHILIS.  193 

appear  late.  It  may  fade  and  reappear  several  times  in  the 
same  patient.     The  eruption  lasts  a  few  weeks. 

2.  Papular  syphilides,  which  are  papules  or  elevations  cov^- 
ered  with  dry  skin,  may  or  may  not  have  a  crust.  They  usu- 
ally appear  from  the  third  to  the  sixth  month  of  the  disease. 
They  may  be  preceded  by  fever,  and  often  reappear  again 
and  again.  They  are  at  first  red,  but  become  brownish.  They 
are  firm  in  feel  and  vary  in  size  from  the  head  of  a  pin  to  a  five- 
cent  piece  or  larger.  They  may  be  present  as  miliar}'  papules, 
lenticular  papules,  papules  which  scale  off  (papulo-squamous 
eruption),  and  moist  papules.  Papules  on  fading  leave  cop- 
pery looking  stains.  Papules  upon  the  palms  and  soles 
constitute  the  so-called  "  palmar  and  plantar  psoriasis,"  which 
appears  from  three  months  to  one  year  after  the  appearance 
of  the  chancre.  These  papules  just  below  the  line  of  the  hair 
on  the  forehead  constitute  the  coi'oiia  venerea.  This  eruption 
affects  especially  the  forehead,  the  neck,  the  abdomen,  and 
the  extremities.  The  papular  or  squamous  syphilide  of  the 
palms  and  soles  begins  as  a  red  spot  which  becomes  elevated 
and  brownish ;  the  epidermis  thickens  and  is  cast  off,  and 
there  then  remains  a  central  red  spot  surrounded  by  under- 
mined skin.  If  papules  are  in  regions  where  they  are  kept 
moist  (as  about  the  anus),  they  become  covered  with  a  sod- 
den gray  film  which  comes  off  and  leaves  the  papule  without 
epidermis.  These  sodden  papules  are  called  "  flat  condylo- 
mata," moist  or  humid  papules  or  plates.  Papules  which  are 
at  first  small  may  become  large.  The  small  or  miliary  papules 
constitute  syphilitic  lichen.  The  lenticular  papules  are  most 
common,  and  strongly  tend  to  scale  off.  The  papular  syph- 
ilide gives  a  worse  prognosis  than  roseola. 

3.  Pustular  syphilides  arise  from  papules.  We  have  acne 
when  the  apex  of  a  papule  softens,  impetigo  when  the  whole 
papule  suppurates,  and  ecthyma  or  rnpia  when  the  corium  is 
also  deeply  involved.  Vesicles  occasionally  precede  pustules. 
The  pustular  eruption  appears  some  months  after  infection 
(later  than  the  papular).  The  pustular  eruption  gives  a  very 
bad  prognosis.  Rupia  is  formed  by  a  pustule  rupturing  or  a 
papule  ulcerating,  the  secretion  drying  and  forming  a  conical 
crust  which  continually  increases  in  height  and  diameter, 
while  the  ulceration  extends  at  the  edges.  When  the  crust 
is  pulled  off  there  is  seen  a  foul  ulcer  with  congested,  jagged, 
and  undermined  edges.  Rupia  may  be  secondary  or  tertiary, 
and  it  invariably  leaves  scars.  It  appears  only  after  at  least- 
six  months  have  passed  since  the  chancre  began.  Secondary 
rupia  is  symmetrical.     Tertiary  rupia  is  asymmetrical. 

13 


194  MODERN  SURGERY. 

4.  Tubercular  syphilides  are  greatly  enlarged  papules 
intermediate  between  ordinary  papules  and  gummata. 

Diagnosis  between  Secondary  and  Tertiary  Syphilides. — A 
secondary  eruption  is  distinguished  from  a  tertiary  eruption 
by  the  following :  the  first  tends  to  disappear,  the  second 
tends  to  persist  and  to  spread ;  the  first  is  general  and  sym- 
metrical, the  second  is  local  and  asymmetrical ;  the  first  does 
not  spread  at  its  edge,  the  second  tends  to  spread  at  its 
edge,  and  this  tendency,  which  is  designated  "  serpiginous," 
produces  an  ulcer  shaped  hke  a  horse-shoe  (Jonathan  Hutch- 
inson). Secondary  lesions  appear  within  certain  limits  of 
time,  develop  regularly  and  are  dispersed  by  mercurial  treat- 
ment. Tertiary  lesions  appear  at  no  fixed  time,  develop 
irregularly,  and  are  not  cleared  up  by  mercury. 

Aflfections  of  the  Mucous  Membranes. — The  chief 
lesions  in  syphilitic  affections  of  the  mucous  membranes  are 
mucous  patches,  warts,  and  condylomata.  The  first  phe- 
nomena of  secondary  syphilis  are,  as  a  rule,  symmetrical 
ulcers  of  the  tonsils,  painless  and  superficial  (Hutchinson). 
The  borders  of  the  ulcers  are  gray,  and  the  areas  are  reni- 
form  in  shape.  They  rarely  last  long.  Catarrhal  inflamma- 
tions often  occur.  Eruptions  appear  on  the  mucous  mem- 
branes or  upon  the  skin.  Mucous  patches  are  papules  de- 
prived of  epithelium ;  they  are  gray  in  color,  are  moist,  and 
give  off  an  offensive  and  virulent  discharge.  They  usually 
appear  as  areas  of  congestion,  swelling,  and  abrasion  of  the 
epidermis  upon  the  lips,  palate,  gums,  tongue,  cheeks,  vagina, 
labia,  vulva,  scrotum,  anus,  and  under  the  prepuce.  A  moist 
papule  of  the  skin  is  really  a  mucous  patch.  These  patches, 
which  are  always  circular  or  oval,  are  among  the  most  con- 
stant lesions  of 'the  secondary  stage,  appearing  from  time  to 
time  during  many  months.  If  a  patch  has  the  papillae  de- 
stroyed, it  is  called  a  "  bald  patch."  If  the  papules  present 
hypertrophied  papillae  fused  together,  there  appear  enlarge- 
ments with  flat  tops,  termed  "  condylomata ;"  if  the  papillae 
of  the  papule  hypertrophy  and  do  not  fuse,  the  growths  are 
called  "  warts."  Mucous  lesions  of  the  mouth  are  commonest 
in  smokers  and  in  those  with  bad  or  neglected  teeth.  Hutchin- 
son says  that  persistence  in  smoking  during  .syphilis  may  cause 
leukomata,  or  persistent  white  patches.  The  vagina  and  lips 
of  the  vulva  are  often  covered  with  mucous  patches.  The 
uterus  may  contain  mucous  lesions  which  poison  the  uterine 
discharge.  The  larynx  may  suffer  from  inflammation,  erup- 
tions, and  ulceration  (hence  the  hoarse  voice  which  is  so 
usual).     The  nasal  mucous  membrane  may  also  suffer.     The 


SYPHILIS.  195 

rectal  mucous  membrane  may  be  attacked  with  patches,  and 
so  may  the  glans  penis  and  inner  surface  of  the  prepuce. 
Early  in  the  secondary  stage  in  some  cases  there  is  a  slight 
mucopurulent  urethral  discharge.  Examination  with  an  en- 
doscope shows  redness  of  the  mucous  membrane  of  the 
anterior  urethra.  The  discharge  is  contagious.  The  con- 
dition may  be  followed  by  constriction  of  the  urethral  cali- 
ber. Mucous  patches  may  form  in  the  urethra  and  ulcera- 
tions can  take  place. 

Aflfections  of  the  Hair. — In  syphilitic  affections  the 
hair  is  shed  to  a  great  extent.  This  loss  may  be  widespread 
(beard,  moustache,  head,  eyebrows,  pubic  hair,  etc.)  or  it  may 
be  limited.  Complete  baldness  sometimes  ensues,  but  this 
is  rarely  permanent.  The  hairs  are  first  noticed  to  come  out 
on  the  comb  ;  on  pulling  them  they  are  found  loose  in  their 
sheaths — so  loose  that  Ricord  has  said  "  a  man  would 
drown  if  a  rescuer  could  pull  only  upon  the  hair  of  the 
head."  This  falling  out  of  the  hair,  which  is  known  as 
"  alopecia,"  begins  soon  after  the  fev^er  or  about  the  time 
of  the  eruption,  but  it  may  be  postponed.  The  skin  of  a 
syphilitic  bald  spot  is  never  smooth,  but  is  scaly.  The  hair 
may  thin  generally,  baldness  may  appear  in  twisting  lines, 
or  it  may  be  complete  only  in  limited  areas.  Alopecia 
results  from  shrinking  of  the  hair-pulp,  death  of  the  hair, 
and  casting  off  of  the  sheath. 

Aflfections  of  the  Nails. — Paronychia  is  inflammation 
and  ulceration  of  the  skin  in  contact  with  a  nail  and  extend- 
ing to  the  matrix.  The  nail  is  cast  off  partially  or  entirely. 
Onychia  is  inflammation  of  the  matrix  and  is  manifested  by 
white  spots,  brittleness  or  extended  opacity,  twisting,  and 
breaking  off  of  the  nail.  The  parts  around  are  not  affected. 
The  damaged  nail  drops  off  and  another  diseased  nail  appears. 

Affections  of  the  Kar. — Temporary  impairment  of 
hearing  in  one  or  both  ears  is  not  uncommon  in  syphilitic 
affections  of  the  ear.  Rarely,  permanent  symmetrical  deaf- 
ness is  produced.  Meniere's  disease  is  sometimes  caused  by 
syphilis. 

Aflfections  of  the  Bones  and  Joints. — In  syphilis 
there  may  be  slight  and  temporary  periostitis.  Pain  and 
tenderness  arise  in  various  bones,  the  pain  being  worse  at 
night  (osteocopic  pains).  The  bones  usually  involved  are 
the  tibiae,  clavicles,  and  skull.  Pain  like  that  of  rheumatism 
affects  the  joints.  Local  periostitis  may  form  a  soft  node 
which  by  ossification  becomes  a  hard  node.  Symmetrical 
synovitis  has  been  noted. 


196  MODERN  SURGERY. 

Affections  of  the  Bye. — Iritis  is  the  commonest  trouble 
of  the  eyes.  It  appears  from  three  to  six  months  after  the 
chancre,  and  begins  in  one  eye,  the  other  eye  soon  becoming 
affected.  The  symptoms  are  a  pink  zone  in  the  sclerotic, 
ciliary  congestion,  muddy  iris,  irregularity  of  the  pupil  accent- 
uated by  atropin,  the  existence  of  pain  and  photophobia,  and 
sometimes  hazy  or  even  blocked  pupil.  Rheumatic  iritis 
causes  much  pain  and  photophobia,  syphilitic  iritis  compara- 
tively little ;  there  is  less  swelling  in  the  first  than  in  the  sec- 
ond ;  the  former  tends  to  recur,  the  latter  does  not.  Iritis  is 
usually  recovered  from,  good  vision  being  retained.  Diffuse 
retinitis  and  disseminated  choroiditis  never  occur  until  a 
number  of  months  have  passed  since  the  infection.  The 
symptoms  are  failure  of  sight,  muscae  volitantes,  and  very 
little  photophobia.  Diagnosis  of  retinitis  and  choroiditis  is 
by  the  ophthalmoscope. 

Affections  of  the  Testes. — Syphilitic  Sarcocele. — 
The  testes  enlarge  from  plastic  inflammation.  Both  glands 
usually  suffer,  but  not  always.  Fluid  distends  the  tunica 
vaginalis.  The  epididymis  escapes.  The  testicle  is  not  the 
seat  of  pain,  is  troublesome  because  of  its  weight,  and  has 
very  little  of  the  proper  sensation  on  squeezing.  The  plas- 
tic exudate  is  generally  largely  absorbed,  but  it  may  organ- 
ize into  fibrous  tissue,  the  organ  passing  into  atrophic 
cirrhosis. 

Intermediate  Period. — Secondary  lesions  cease  to 
appear  in  from  eighteen  months  to  three  years.  In  the 
intermediate  period  no  symptoms  may  appear,  but  the  dis- 
ease is  still  for  some  time  latent  and  is  not  cured.  Symp- 
toms may  appear  from  time  to  time.  These  symptoms, 
which  are  called  "  reminders,"  are  not  so  severe  as  tertiary 
symptoms  ;  reminders  are  apt  to  be  symmetrical,  and  they 
do  not  closely  resemble  secondary  lesions.  Among  the  re- 
minders we  may  tiame  palmar  psoriasis  and  sarcocele.  Sar- 
cocele in  this  stage  is  bilateral  and  rarely  painful.  Bilateral 
indolent  epididymitis  occasionally  occurs.  Sores  on  the 
tongue,  a  papular  skin-eruption,  and  choroiditis  may  arise. 
Gummata  occur  in  this  stage,  but  they  are  apt  to  be  sym- 
metrical and  non-persistent.  Arteritis  occurs,  beginning  in 
the  intima  or  adventitia,  and  causing,  it  may  be,  aneurysm, 
embolism,  or  thrombosis.  Obliterative  endarteritis  may 
cause  gangrene.  This  vascular  condition  is  frequent  in  the 
brain ;  thrombosis  may  occur,  in  which  case  a  paralysis 
comes  on  gradually,  preceded  by  numbness,  although  sud- 
den paralysis  may  occur.     These  paralyses  may  be  limited^ 


SYPHILIS.  197 

extensive,  transitory,  or  permanent.  The  nervous  system 
often  suffers  in  this  stage  (anesthetic  areas  and  retinitis). 
The  viscera  are  often  congested  and  infiltrated  (tonsils,  liver, 
spleen,  kidneys,  and  lungs). 

Tertiary  Syphilis. — This  stage  is  not  often  reached,  the 
disease  being  cured  before  it  has  been  attained.  It  is  re- 
garded by  many  as  not  so  much  a  stage  of  syphilis  as  a 
condition  of  impaired  nutrition  which  results  from  the  dis- 
ease. This  view  finds  confirmation  in  the  fact  that  tertiary 
lesions  do  not  furnish  the  contagion.  The  primary  stage 
disappears  without  treatment,  the  secondary  stage  tends 
ultimately  to  spontaneous  disappearance,  but  tertiary  lesions 
tend  to  persist  and  to  recur.  Tertiary  lesions  may  be  single 
or  may  be  widely  scattered ;  when  multiple  they  are  not 
symmetrical  except  by  accident.  These  lesions  may  attack 
any  tissue,  even  after  many  years  of  apparent  cure  ;  they  all 
tend  to  spread  locally,  they  all  leave  permanent  atrophy  or 
thickening,  they  all  tend  to  relapse,  and  a  local  influence  is 
often  an  exciting  cause. 

Tertiary  skin-eruptions  are  liable  to  ulcerate.  Various 
eruptions  may  occur :  papular  syphilides,  pustular  syph- 
ilides,  gummatous  syphilides,  serpiginous  syphilides,  and 
pigmentary  syphilides.  The  characteristic  syphilide  is  riipia, 
which  is  formed  by  a  pustule  rupturing  or  a  papule  ulcer- 
ating. A  crust  forms  because  of  the  drying  of  the  discharge, 
ulceration  continues  under  the  crust,  new  crusts  form,  and, 
as  the  ulcer  is  constantly  increasing  peripherally,  the  new 
crusts  are  larger  in  diameter  than  the  old  ones,  and  the 
mass  assumes  the  form  of  a  cone.  An  ulcer  is  exposed 
by  tearing  off  the  crust,  which  ulcer  has  destroyed  the 
deeper  layers  of  the  skin,  and  on  healing  always  leaves  a 
permanent  scar. 

Serpiginous  ulcers  are  common  in  tertiary  syphilis,  and 
are  especially  common  about  the  knees,  nostrils,  forehead, 
and  lips.  Serpiginous  ulceration  is  spoken  of  as  syphilitic 
lupus.  It  is  preceded  by  a  widespread,  brown-colored  nod- 
ular cutaneous  infiltration.  The  nodules  suppurate,  run 
together,  crust,  and  produce  an  ulcer  which  spreads  rapidly 
and  is  the  shape  of  a  horseshoe. 

Gumma. — The  gumma  is  the  typical  tertiary  lesion.  A 
gumma  arises  from  an  inflammation  the  products  of  which 
cannot  organize  for  want  of  sufficient  blood-supply,  and 
which  consequently  undergo  fatty  degeneration.  A  gumma 
presents  a  center  of  gummy  degeneration,  a  surrounding 
area  of  immature  fibrous  tissue,  and  an  outer  zone  of  em- 


198  MODERN  SURGERY. 

bryonic  tissue  and  leukocytes.  A  gumma,  when  it  is  spon- 
taneously evacuated,  exhibits  a  small  opening  or  many  open- 
ings with  very  thin  red  and  undermined  edges ;  the  ulcer  is 
slow  to  heal,  and  forms  a  thin  scar,  white  in  the  center,  but 
pigmented  at  the  margins  and  usually  depressed  (Jonathan 
Hutchinson,  Jr.).  These  ulcers  when  once  healed  rarely 
recur.  Such  ulcers  are  apt  to  be  seen  upon  the  legs.  The 
gummatous  ulcer  is  deep,  circular  in  outline,  with  under- 
mined edges  and  an  uneven  floor  covered  with  a  thick  white 
adherent  slough.  Sometimes  there  is  no  slough,  but  an 
extensive  area  is  infiltrated.  A  gummatous  ulcer  may  coa- 
lesce with  one  or  more  adjacent  ulcers.  The  discharge  is 
scanty  and  tenacious.  A  gumma  in  the  internal  organs  may 
become  a  fibrous  mass.  These  gummata  form  in  the  skin, 
subcutaneous  tissues,  muscles,  tongue,  joints,  bursas,  testes, 
spinal  cord,  brain,  and  internal  organs.  In  tertiary  syphilis 
an  inflammation  may  not  form  a  circumscribed  gumma,  but, 
instead,  may  produce  a  diffuse  degenerating  mass.  This 
type  of  inflammation,  which  is  seen  in  bones,  is  called  "  gum- 
matous." A  healing  gumma  in  a  mucous  canal  such  as  the 
rectum  or  larynx  causes  thickening  and  stricture.  Tertiary 
syphilis  is  a  most  common  cause  of  amyloid  degeneration 
and  arterial  and  nervous  sclerosis. 

Various  Lesions.— Hutchinson  enumerates  the  lesions 
of  tertiary  syphilis  as  follows :  Periostitis,  forming  nodes  or 
causing  sclerotic  hypertrophy  or  suppuration  or  necrosis ; 
gummata  in  various  parts ;  disease  of  the  skin  of  the  type 
of  rupia  or  lupus  ;  gumma  or  inflammation  of  tongue,  causing 
sclerosis  ;  structural  changes  in  the  nervous  system,  causing 
ataxia,  ophthalmoplegia  externa  and  interna,  general  paresis, 
optic  atrophy,  and  paralyses  of  cerebral  nerves ;  amyloid 
degenerations ;  and  chronic  inflammation  of  certain  mucous 
membranes  (of  the  mouth,  pharynx,  vagina,  rectum,  etc.), 
with  thickening  and  ulceration.  Unilateral  enlargement  of 
the  epididymis  is  sometimes  noted,  the  mass  feeling  heavy, 
aching  a  little,  but  not  being  very  tender.  Unilateral  sarco- 
cele  may  be  met  with. 

Visceral  Syphilis. — In  visceral  syphilis  the  lungs  may 
undergo  fibroid  induration  (syphilitic  phthisis).  Syphilitic 
phthisis  is  a  nonfebrile  malady.  Gummata  may  form  in  the 
heart,  liver,  spleen,  or  kidneys.  The  capsule  and  fibrous  septa 
of  the  liver  may  thicken,  the  organ  being  puckered  from  con- 
traction. Amyloid  changes  may  appear  in  any  of  the  vis- 
cera. Albuminuria  may  occur  in  tertiary  syphilis.  It  may 
be  caused  by  fibroid  changes  in  the  kidneys,  by  the  formation 


SYPHILIS.  199 

of  gummata,  or  by  amyloid  degeneration.  Its  occurrence 
should  be  watched  for.  Mercury  and  iodid  of  potassium 
have  been  suspected  as  causative  of  albuminuria. 

Nervous  syphilis  may  be  manifested  in  disorders  of  the 
brain,  cord,  or  nerves.  Brain  syphilis  is  usually  a  late  phe- 
nomenon (from  one  to  thirty  years),  and  is  more  apt  to  ap- 
pear after  light  secondaries.  The  lesion  may  be  gumma  of 
the  membranes  (tumor),  gummatous  meningitis,  arterial 
atheroma,  or  obliterative  endarteritis.  A  gumma  may 
eventuate  in  a  scar,  a  cyst,  or  a  calcareous  mass.  The 
symptoms  of  brain  syphilis  depend  on  the  nature,  seat, 
and  rate  of  development  of  the  lesions.  It  is  to  be  noted 
that  syphilitic  palsy  is  apt  to  be  limited,  progressive,  and 
incomplete.  Epilepsy  appearing  after  the  thirtieth  year  is 
very  probably  specific  if  alcohol  as  a  cause  can  be  ruled 
out  (Wood).  Persistent  headache,  tremor,  insomnia  or  som- 
nolence, transitory,  limited,  and  erratic  palsies  ;  unnatural 
slowness  of  utterance,  amnesia,  vertigo,  and  epilepsy  are 
very  suggestive.  Sudden  ptosis  is  very  significant ;  so  is 
sudden  palsy  of  one  or  more  of  the  extrinsic  eye-muscles.  In 
syphilitic  insomnia  the  patient  cannot  get  to  sleep  at  night  for 
a  long  while,  but  when  he  once  gets  to  sleep  he  reposes  well. 
The  more  usual  type  of  insanity  is  a  likeness  or  counterpart 
of  general  paralysis.  Spinal  syphilis  may  cause  sclerosis,  a 
condition  like  Landry's  paralysis,  softening,  and  tumor. 
Neuritis  is  not  uncommon  in  syphilis. 

Treatment  of  Primary  Stage. — A  chancre  should  not 
be  excised.  The  disease  is  constitutional  when  the  chancre 
appears,  and  excision  and  cauterization  inflict  needless  pain 
and  do  no  good.  The  initial  lesion  should  never  be  cauter- 
ized unless  it  is  phagedenic  or  becoming  so.  Order  the  patient 
to  soak  the  penis  for  five  minutes  twice  daily  in  warm  salt 
water  (a  teaspoonful  of  salt  to  a  cupful  of  water),  and  then 
to  spray  the  sore  by  an  atomizer  with  peroxid  of  hydrogen 
(14-volume  solution  of  peroxid  diluted  with  an  equal  bulk 
of  water).  The  ulcer  is  then  dried  with  absorbent  cotton 
and  on  it  is  dusted  a  powder  of  equal  parts  of  bismuth 
and  calomel.  The  buboes  in  the  groin  require  no  local 
treatment  unless  they  tend  to  suppurate.  If  they  persist 
or  become  large,  paint  them  with  iodin  or  smear  ichthyol  oint- 
ment over  them,  and  apply  a  spica  bandage  of  the  groin. 
Ichthyol  and  lanolin  make  an  excellent  application  for  the 
enlarged  glands,  and  so  does  mercurial  ointment.  Some 
authorities  give  mercury  in  this  stage,  claiming  that  it  pre- 
vents secondaries.    The  younger  Gross  opposed  this  strongly, 


200  MODERN  SURGERY. 

and  affirmed  a  wish  to  see  the  secondary  eruption — first, 
because  it  proves  the  diagnosis ;  and,  second,  because  it 
affords  valuable  prognostic  indications  (an  erythematous 
eruption  means  a  light  case ;  an  early  pustular  eruption 
means  a  grave  case  with  serious  complications).  White 
will  not  order  mercury  until  constitutional  symptoms  de- 
velop. If  phagedena  arises,  place  the  patient  at  once  upon 
stimulants  and  nutritious  diet.  Give  him  quinin,  iron,  strych- 
nin, and  whiskey.  Secure  sleep.  Destroy  the  ulcer  by  the 
use  of  nitric  acid  or  the  electric  cautery  while  the  patient  is 
anesthetized.  Dust  with  iodoform  and  dress  with  wet  antisep- 
tic gauze.  Several  times  a  day  change  the  dressings,  and  at 
each  change  spray  with  peroxid  of  hydrogen,  irrigate  with 
bichlorid  of  mercury  solution,  and  dust  with  iodoform.  It 
may  be  necessary  to  cauterize  several  times.  These  cases 
are  sometimes  fatal  and  usually  produce  great  destruction  of 
tissue. 

Treatment  of  Secondary  Stage. — In  the  secondary 
stage  the  aim  is  to  cure  the  disease.  That  it  can  be  cured 
is  known  from  the  fact  that  reinfection  occurs  in  some 
persons.  The  old  axiom,  "  Syphilis  once,  syphilis  ever,"  is 
not  true.  Mercury  must  be  used,  the  form  being  a  matter 
of  choice.  Fournier  first  advocated  intermittent  treatment. 
In  this  plan  give  gr.  \  of  protiodid  of  mercury  daily  for 
six  months,  then  stop  a  month ;  then  give  mercury  for  three 
months,  then  stop  two  months.  During  the  first  year  the 
patient  is  under  treatment  nine  months,  and  during  the 
second  year  eight  months.  Some  prefer  the  intermittent 
and  others  the  continuous  plan  of  treatment.  White 
greatly  prefers  the  continuous  plan.  The  rule  in  most  cases 
is  to  give  mercury  for  two  years.  Find  the  patient's  dose 
of  tolerance,  and  keep  him  on  this  amount.  Gross'  rule 
for  continuous  treatment  was  to  order  pills  of  the  green 
iodid  of  mercury,  each  pill  containing  gr.  \.  The  patient 
was  ordered  one  pill  after  each  meal  to  begin  with ;  the  next 
day  he  took  two  pills  after  breakfast ;  the  following  day,  two 
after  dinner,  and  so  on,  adding  one  pill  every  day.  This 
advance  was  continued  until  there  was  slight  diarrhea, 
griping,  a  metallic  taste,  or  tenderness  on  snapping  the 
teeth  together,  whereupon  one  pill  was  taken  off  each  day 
until  all  unfavorable  symptoms  disappeared.  This  experi- 
mentation finds  a  dose  on  which  the  patient  can  be  kept 
with  entire  safety  for  a  long  time  ;  but  if  it  is  found  that  colic 
or  diarrhea  is  apt  to  recur,  there  must  be  added  to  each  pill 
gr.  ^  of  opium.     The  patient  is  given  mercury  in  this  way 


SYPHILIS.  20 1 

for  two  years.  Every  time  new  symptoms  appear  the  dose 
is  raised,  and  as  soon  as  they  disappear  it  is  lowered  to 
the  standard.  If  the  protiodid  is  not  tolerated,  give  the 
bichlorid : 

R.   Hydrarg.  chlor.  corros.,  gi"- j '? 

Syr.  sarsaparillae  comp.,  fSi'j- — M. 

Sig.  f^j,  in  water,  after  meals. 

Mercury  with  chalk  in  i -grain  doses  four  times  a  day,  with 
or  without  Dover's  powder  in  ^-grain  doses,  can  be  used. 
Mercurial  inunctions  produce  a  rapid  effect,  but  irritate  the 
skin.  There  can  be  used  once  a  day  \  dram  of  oleate  of 
mercury  (10  per  cent.)  or  i  dram  of  mercurial  ointment, 
rubbed  in,  one  day  on  the  inside  of  one  thigh  and  the  next 
day  on  the  inside  of  the  other  thigh  ;  next,  the  inside  of  one 
arm  and  then  the  other  arm  ;  next,  one  groin  and  then  the 
other  groin,  and  so  on.  After  the  rubbing  the  patient  puts 
on  underclothes  and  goes  to  bed,  and  in  the  morning  takes 
a  bath.  The  ointment  may  be  smeared  on  a  rag,  which  is 
then  worn  between  the  stocking  and  sole  of  the  foot  during 
the  day. 

Fumigation  is  performed  by  volatilizing  each  night  3j  of 
calomel.  The  patient  sits  naked  on  a  cane-seat  chair,  the 
calomel  is  put  upon  an  iron  plate  under  the  chair  and  is 
heated  by  an  alcohol  lamp  beneath  the  plate,  and  wrapped 
around  the  patient  is  a  blanket  which  drops  tent-like  to  the 
floor.  The  skin  becomes  coated  with  calomel,  and  the  sub- 
ject, after  putting  on  woollen  drawers  and  an  undershirt, 
gets  into  bed.  Hypodermatic  injections  of  mercury  are  used 
by  some  physicians.  They  cause  an  eruption  to  disappear 
rapidly,  but  may  produce  abscesses,  and  relapses  are  prone 
to  occur.  The  usual  plan  is  to  give  daily  a  hypodermatic 
injection  of  corrosive  sublimate  deep  into  the  back  or  but- 
tocks, the  dose  being  gr.  \  of  the  drug.  Thirty  such  injec- 
tions are  used  unless  some  indication  points  to  their  discon- 
tinuance sooner.  The  treatment  is  then  stopped.  If  the 
symptoms  recur,  however,  the  patient  is  given  another 
course,  the  daily  dosage  being  gr.  \,  the  treatment  being 
again  stopped  after  thirty  injections,  but  continued  anew  in 
^-grain  doses  if  the  symptoms  recur.  Orville  Horwitz 
has  recently  made  thorough  trial  of  this  method,  and  arrives 
at  the  following  conclusions :  it  will  not  abort  the  disease ; 
it  should  never  be  a  routine  treatment ;  in  suitable  cases  it  is 
very  valuable  for  symptomatic  use,  as  when  lesions  on  the 
face  or  in  important  structures  make  a  rapid  impression  de- 


202  MODERN  SURGERY. 

sirable  or  necessary  ;  in  cases  which  obstinately  relapse  under 
other  treatment,  and  in  syphilis  of  the  nervous  system.  Some 
physicians  use  the  gray  oil. 

J.  William  White,  after  a  large  experience  with  this 
method,  says  that  hypodermatic  injections  of  corrosive 
sublimate  are  painful  and  are  strongly  objected  to  by  many 
patients ;  that  this  method  of  treatment  is  occasionally  dan- 
gerous and  even  fatal ;  that  it  is  liable  to  be  followed  by  local 
complications  (erythema,  nodosities,  cellulitis,  abscess,  slough- 
ing) ;  that  it  cannot  be  carried  out  by  the  patient,  but  requires 
the  surgeon's  constant  intervention.  This  distinguished  syph- 
ilographer  concludes  that  hypodermatic  medication  does  not 
offer  advantages  justifying  its  use  as  a  systematic  method  of 
treatment,  and  that  it  encourages  insufficient  treatment — 
those  "  short  heroic  courses  "  which  Hutchinson  shows  are 
followed  by  the  gravest  tertiary  lesions.  "  The  claim  that 
by  a  few  injections  the  time  of  treatment  can  be  measured  by 
months  or  even  by  weeks,  instead  of  by  years,  would  seem, 
as  Mauriac  has  said,  to  involve  the  idea  that  mercury  given 
hypodermatically  acquires  some  new  and  powerful  curative 
property  which,  given  in  other  ways,  it  does  not  possess."  ^ 
Some  surgeons  employ  intravenous  injections  of  mercury. 
Lane  injects,  at  first  every  other  day  and  later  daily,  20lfTl  of 
a  I  per  cent,  solution  of  cyanid  of  mercury.  The  injection 
is  made  in  a  vein  in  front  of  the  elbow,  the  skin  is  rendered 
aseptic,  a  fillet  is  tied  around  the  arm,  the  needle  is  inserted, 
the  fillet  is  loosened,  the  fluid  is  injected,  and  the  needle  is 
withdrawn.  This  method  of  using  mercury  is  painless  and 
produces  a  rapid  effect.  It  may  be  used  in  nervous  syphilis, 
but  is  not  used  as  a  routine.  In  whatever  way  mercury  is  given, 
do  not  let  it  salivate  (hydrargyrism).  Always  remember  that 
mercury  may  cause  albuminuria.  Examine  the  urine  at  regu- 
lar intervals.  If  albumin  appears  in  urine,  cut  down  the  dose 
or  stop  the  drug  for  a  time.  In  the  beginning  of  a  case  of 
syphilis,  if  the  kidneys  are  found  to  be  diseased,  give  the 
mercury  cautiously,  and  never  fail  to  examine  the  urine  at 
regular  intervals. 

Acute  Ptyalism,  or  Salivation. — In  acute  ptyalism  the 
saliva  becomes  thick  and  excessive  in  amount ;  the  gums  be- 
come tender  (found  first  by  snapping  the  teeth),  spongy,  and 
tend  to  bleed;  a  metallic  taste  is  complained  of;  the  breath 
becomes  fetid  ;  all  the  oral  structures  swell ;  the  teeth  loosen ; 
the  saliva  is  produced  in  great  quantity  ;  and  there  are  purging, 

^  J.  William  White,  in  Morrow's  System  of  Genito-winary  Diseases,  Syph- 
ilology,  and  Dermatology. 


SYPHILIS.  203 

colic,  and  exhaustion.  Sometimes  there  is  fever  and  a  diffuse 
scarlitiniform  eruption  upon  the  skin.  A  chronic  hydrargy- 
rism  may  be  shown  by  gastro-intestinal  disorder,  emaciation, 
mental  depression,  weakness,  albuminuria,  and  tremor.  To. 
avoid  salivation  cautiously  advance  the  dose  and  instruct  the 
patient  as  to  the  first  signs.  He  should  use  a  soft  toothbrush 
and  an  astringent  mouth-wash  (gr.  xlviij  of  boric  acid  to 
5iv  each  of  Listerin  and  water).  When  ptyalism  begins,  stop 
the  drug.  Employ  the  above  mouth-wash  or  one  composed 
of  a  saturated  solution  of  chlorate  of  potassium.  Order  gr. 
yI^^  of  atropin  twice  a  day,  and  in  bad  cases  spray  the  mouth 
with  peroxid  of  hydrogen  and  use  silver  nitrate  locally  (gr. 
XX  to  sj).  Give  stimulants  and  nutritious  food — iron,  quinin, 
and  strychnin.  A  weekly  Turkish  bath  is  of  great  use.  In 
chronic  hydrargyrism  stop  the  drug,  use  tonics,  stimulants, 
open-air  exercise,  Turkish  baths,  and  good  food.  The  chlo- 
rid  of  gold  and  sodium  forms  a  good  substitute  drug.  The 
use  of  iodid  of  potassium  is  of  questionable  value. 

Treatment  of  Complications  in  the  Secondary  Stage. — 
The  complications  of  the  secondary  stage  usually  require  local 
applications  in  addition  to  general  remedies.  Mucous  patches 
in  the  mouth  should  be  touched  with  bluestone  every  day,  an 
astringent  mouth-wash  being  employed  several  times  daily. 
If  the  patches  ulcerate,  they  should  be  touched  twice  a  day 
with  lunar  caustic ;  if  these  areas  proliferate,  they  should  be 
excised  and  burned.  Vegetations  or  growing  papules  on  the 
skin  must,  if  calomel  powder  fails  to  remove  them,  be  cut 
away  with  scissors  and  be  cauterized  with  chromic  acid  or 
with  the  Paquelin  cautery.  Condylomata  demand  washing 
with  ethereal  soap  several  times  daily,  thorough  drying,  dust- 
ing with  equal  parts  of  calomel  and  subnitrate  of  bismuth  or 
with  borated  talcum,  and  covering  with  dry  bichlorid  gauze. 
If  these  simple  procedures  fail,  excise  and  cauterize. 

For  psoriasis  of  the  palms  and  soles  diachylon  ointment, 
mercurial  plaster,  or  painting  with  tincture  of  iodin  should 
be  employed.  Ulcers  of  paronychia  are  dressed  with  iodo- 
form and  corrosive-sublimate  gauze.  Deep  cutaneous  ulcers 
are  cleaned  once  a  day  with  ethereal  soap,  then  sprayed  with 
peroxid  of  hydrogen,  dressed  with  iodoform  and  corrosive- 
sublimate  gauze,  and  bandaged.  When  granulation  is  well 
established  dress  with  i  part  of  unguent,  hydrarg.  nitratis  to 
7  parts  of  cosmolin.  In  sarcocele  mercurial  ointment  should 
be  used  or  the  testicle  be  strapped.  Alopecia  requires  that 
the  hair  be  kept  short  and  every  night  the  scalp  be  cleaned 
with  equal  parts  of  green  soap  and  alcohol  rubbed  into  a 


204  MODERN  SURGERY. 

lather  with  water.  After  the  soap  is  washed  out  some  hair 
tonic  should  be  rubbed  into  the  scalp  with  a  sponge.  A 
favorite  preparation  of  Erasmus  Wilson's  consisted  of  the  fol- 
lowing ingredients  : 

R.  01.  amjgd.  dul., 

Liq.  ammonice,  ad.  f  ^j  ; 

Spt.  rosemarini, 

Aquse  mellis,  aa.  f^iij. 

M.  Ft.  lotio. 

One  part  of  tincture  of  cantharides  to  8  parts  of  castor  oil 
may  be  rubbed  into  the  scalp.  Solutions  of  quinin  are 
esteemed  by  some. 

In  treating  persistent  skin-lesions,  inunctions,  injections,  or 
fumigations  may  be  used ;  some  prefer  mercurial  baths.  Baths 
are  suited  to  patients  with  delicate  skins,  to  those  whose 
digestion  fails  from  mercury  by  the  stomach,  and  to  those 
whose  lungs  will  not  tolerate  fumigations.  Half  an  ounce 
of  corrosive  sublimate  with  4  scruples  of  sal  ammoniac  are 
mixed  in  about  4  ounces  of  water ;  this  is  added  to  a  bath  at 
a  temperature  of  95°.  The  patient  gets  into  this  bath,  covers 
the  tub  with  a  blanket,  leaving  only  his  head  exposed,  and 
remains  in  the  bath  an  hour  or  so.  These  baths  may  easily 
cause  salivation. 

In  every  case  of  syphilis,  no  matter  what  constitutional  or 
local  treatment  is  used,  the  general  health  of  the  patient  must 
be  watched  and  the  use  of  tobacco  be  stopped,  as  its  use  ren- 
ders certain  the  development  of  mucous  patches  and  causes 
them  to  persist.  Alcohol  as  a  beverage  must  be  cut  off:  it  is 
to  be  used  only  as  a  medicine  for  debility  and  weakness  of 
assimilation.  An  open-air  life  to  a  great  degree  must  be  in- 
sisted upon,  and  care  be  observed  as  to  protection  from  damp 
and  cold.  Flannels  must  be  worn  in  winter.  Have  the  patient 
sponge  the  chest  and  shoulders  every  morning  with  cold  or  with 
tepid  water  and  then  with  alcohol,  dry  himself  with  a  rough 
towel,  and  take  a  hot  bath  twice  a  week  or  a  Turkish  bath 
once  a  week.  He  should  wash  the  anus  and  nates  after  every 
stool,  and  ought  to  dust  the  axillae,  scrotum,  perineum,  and 
internatal  region  once  a  day  with  borated  talc.  The  teeth  are 
to  be  looked  to  and  put  in  perfect  order,  a  soft  brush  being 
used  twice  a  day  and  an  astringent  mouth-wash  being  fre- 
quently employed.  Meat  and  milk  are  largely  to  be  used. 
The  patient  should  be  weighed  weekly :  any  falling  off  in 
weight  is  an  indication  for  tonics,  concentrated  food,  and  cod- 
liver  oil.     If  a  patient's  health  continues  to  fail  on  mercury, 


SYPHILIS.  205 

the  drug  should  be  stopped  for  some  time  and  the  patient  be 
treated  with  iron,  chlorid  of  gold  and  sodium,  baths,  fresh  air, 
cod-liver  oil,  and  nourishing  foods.  In  treating  secondary 
syphilis,  give  mercury  for  at  least  eighteen  months  and  bet- 
ter for  two  years.  Reminders  require  mixed  treatment  (mer- 
curials and  iodids). 

Tertiary  Stage. — If  at  any  time  during  the  case  there 
appear  tertiary  symptoms,  the  patient  should  be  put  on  mixed 
treatment.  In  any  case,  after  two  years  of  mercury  add  iodid 
of  potassium  to  the  treatment.  White's  rule  is  to  use  this 
mixed  treatment  for  at  least  six  months  (if  any  symptoms  ap- 
pear), the  six-months  course  dating  from  their  disappearance. 
This  emphasizes  the  fact  that  the  iodids  alone  will  not  cure 
tertiary  syphilis.  In  obstinate  tertiaries  or  in  nervous  syph- 
ilis the  iodids  should  be  run  up  to  an  enormous  amount  (from 
30  to  250  grains  per  day).  An  easy  way  to  give  iodid  is  to 
order  a  saturated  solution  each  drop  of  which  solution  equals 
one  grain  of  the  drug.  Each  dose  of  the  iodid  is  given  one 
hour  after  meals  and  in  at  least  half  a  glass  of  water.  If 
the  iodid  disagrees,  it  may  be  given  in  water  containing  one 
dram  of  aromatic  spirits  of  ammonia  or  in  milk.  The  iodid 
of  sodium  may  be  tolerated  better  than  the  potassium  salt, 
or  the  iodids  of  sodium,  potassium,  and  ammonium  may  be 
combined.  In  giving  the  iodids  begin  with  a  small  dose. 
During  a  course  of  the  iodid  always  give  tonics  and  insist  on 
plenty  of  fresh  air.  Arsenic  tends  to  prevent  skin-eruptions. 
The  iodids  when  they  disagree  produce  iodism — a  condition 
which  is  first  made  manifest  by  running  of  the  nose  and  the 
eyes.  In  some  subjects  there  is  an  outbreak  of  acne,  vesicu- 
lar eruptions  or  even  bullae,  or  hemorrhages.  Iodism  calls 
for  a  reduction  in  dosage,  and,  if  severe  or  persistent,  for  the 
abandonment  of  the  drug.  Some  patients  who  cannot  take 
the  alkalin  iodids  may  take  syrup  of  hydriodic  acid.  After 
the  patient  has  been  for  six  months  under  mixed  treatment 
without  a  symptom,  stop  all  treatment  and  await  develop- 
ments. If  during  one  year  no  symptoms  recur,  the  patient 
is  probably  cured ;  if  symptoms  do  recur,  there  must  be  six 
months  more  of  treatment  and  another  year  of  watching. 
Fournier  has  insisted  that  it  is  a  great  wrong  to  tell  a  syph- 
ilitic that  he  can  never  marry.  He  must  not  marry  until  he 
is  cured,  and  he  is  not  cured  until,  after  the  cessation  of  the 
use  of  iodid,  he  goes  one  year  without  treatment  and  without 
symptoms. 

Hereditary  Syphilis. — Transmitted  cong-enital  syph- 
ilis is  a  hereditary  syphilis  manifest  at  birth.    Acquired  syph- 


2o6  MODERN  SURGERY. 

ilis  (except  in  the  case  of  a  Avoman  who  obtains  the  disease 
from  a  fetus)  always  presents  the  chancre  as  an  initial  lesion  ; 
hereditary  syphilis  never  does.  Hereditary  syphilis  may  pre- 
sent itself  at  birth,  and  usually  shows  itself  within,  at  most, 
the  first  six  months  of  extra-uterine  life.  In  rare  cases  (tardy 
hereditary  syphilis)  the  disease  does  not  become  manifest  until 
puberty. 

Rules  of  Inheritance. — According  to  Von  Zeissl,^  the  rules 
of  inheritance  are  as  follows  : 

1.  If  one  parent  is  syphilitic  at  the  time  of  procreation,  the 
child  may  be  syphilitic. 

2.  Syphilitic  parents  may  bring  forth  healthy  children. 

3.  If  a  mother,  healthy  at  procreation,  bears  a  child  syph- 
ilitic from  the  father,  the  mother  must  have  latent  pox  or 
must  be  immune,  having  become  infected  through  the  pla- 
cental circulation.  She  often  shows  no  symptoms,  having 
received  the  poison  gradually  in  the  blood,  and  having  thus 
received,  it  may  be  said,  preventive  inoculations.  Certain  it 
is  that  mothers  are  almost  never  infected  by  suckling  their 
own  syphilitic  children  (Colles's  law). 

4.  If  both  parents  were  healthy  at  the  time  of  procreation, 
and  the  mother  afterward  contracts  syphilis,  the  child  may 
become  syphilitic,  and  the  earlier  in  the  pregnancy  the  mother 
is  diseased,  the  more  certain  is  the  child  to  be  tainted.  This 
is  known  as  "infection  in  utero." 

5.  The  more  recent  the  parental  syphilis,  the  more  certain 
is  infection  of  the  offspring.    The  children  are  often  stillborn. 

6.  When  the  disease  is  latent  in  the  parents  it  is  apt  to  be 
tardy  in  the  children. 

7.  The  longer  the  time  which  has  passed  since  the  dis- 
appearance of  parental  symptoms,  the  more  improbable  is 
infection  of  the  children. 

8.  In  most  instances  parental  syphilis  grows  weaker,  and 
after  the  parents  beget  some  tainted  children  they  bring  forth 
healthy  ones. 

Syphilis  in  the  mother  is  more  dangerous  to  the  offspring 
than  syphilis  in  the  father.  The  frequent  immunity  of  the 
mother  is  due  to  the  fact  that  her  tissues  produce  antitoxins 
under  the  influence  of  the  virus. 

Many  women  who  labor  under  hereditary  syphilis  are 
sterile.  Many  syphilitic  women  abort,  usually  before  the 
eighth  month.  The  fetus  very  often  dies  at  an  early  period 
of  gestation.  This  may  be  due  to  a  gummatous  placenta  or 
to  a  degeneration  of  placental  follicles. 

1  Pathology  and  Treatment  of  Syphilis. 


SYPHILIS.  207 

Evidences  of  Hereditary  Syphilis  (manifest  at,  or  oftener 
soon  after,  birth). — Hutchinson  says  that  at  birth  the  skin 
is  almost  invariably  clear.  In  from  six  to  eight  weeks 
"snuffles"  begin,  which  are  soon  followed  by  a  skin-eruption, 
by  body-wasting,  and  by  a  chain  of  secondary  symptoms 
(iritis,  mucous  patches,  pains,  condylomata,  etc.).  The  child 
looks  like  a  withered-up  old  man.  Eruptions  are  met  with 
on  the  palms  and  soles.  Intertrigo  is  usual.  Cracks  occur 
at  the  angles  of  the  mouth,  and  leave  permanent  radiating 
scars.  The  abdomen  is  tumid,  and  there  is  apt  to  be  exhaust- 
ing diarrhea.  The  secreting  and  absorbing  glands  of  the 
intestinal  track  atrophy.^  Enlargement  of  spleen  and  liver 
occurs.  Sometimes  synovitis  or  arthritis  arises.  Atrophic 
lesions  may  appear  in  the  bones.  In  the  skull  the  bone  may 
be  softened  by  removal  of  its  salts  or  be  thinned  by  the 
pressure  of  the  brain.  In  the  long  bones  the  epiphyseal  ends 
suffer,  the  attachment  of  epiphysis  to  shaft  is  weak,  and  sepa- 
ration is  easily  induced.  Epiphysitis  is  common  and  rarely 
causes  pain.  Epiphysitis  rarely  suppurates  unless  in  chil- 
dren who  are  old  enough  to  walk  (Coutts).  Osteophytic 
lesions  of  the  skull  are  shown  by  symmetrical  spots  of 
thickening  upon  the  parietal  and  frontal  bones  (natiform 
skulls).  In  the  long  bones  osteophytes  are  frequently  formed. 
A  child  with  precocious  hereditary  syphilis  is  apt  to  die,  but 
if  it  lives  from  six  months  to  one  year  the  symptoms  for  a 
time  disappear  and  for  years  the  disease  may  be  latent. 
Diagnosis  is  difficult  after  the  third  or  fourth  year,  especially 
if  the  disease  be  associated  with  rickets  or  tuberculosis.  When 
the  disease  begins  again  the  symptoms  are  various,  namely : 
noises  in  the  ears,  often  followed  b}^  deafness ;  interstitial 
keratitis ;  dactylitis  (specific  inflammation  of  all  the  struc- 
tures of  a  finger) ;  synovitis  in  any  joint ;  ossifying  nodes  ;  de- 
velopmental osseous  defects  ;  suppurative  periostitis  ;  ulcera- 
tions ;  death  of  bone ;  falling  in  of  nose ;  nervous  maladies  ; 
occasionally  sarcocele,  etc.  In  hereditary  syphilis  the  eye- 
symptoms  are  of  great  diagnostic  importance.  In  212  cases 
of  congenital  syphilis  Fournier  found  eye-trouble  in  loi. 
Keratitis  and  choroiditis  are  the  most  usual  forms  (Silex). 
Bone-trouble  occurs  in  almost  half  of  the  cases,  but  is  not 
often  severe  enough  to  cause  symptoms.  The  tongue  often 
shows  a  smooth  base  (Virchow's  sign).  Hirschberg  believed 
choroiditis  to  be  pathognomonic. 

Diagnosis. — In  the  diagnosis  of  hereditary'  syphilis  the 
condition  of  the  teeth  is  of  much  importance  :  the  temporary 

^  Coutts,  in  Brif.  Mid.  Jour.,  1894,  No.  1843. 


208  MODERN  SURGERY. 

teeth  decay  soon,  but  present  no  characteristic  defect.     If  the 
upper   permanent    central   incisors   are    examined,  they  are 

found  defective.  Other  teeth 
may  show  defects,  but  in  these 
alone  are  defects  almost  sure  to 
appear.  In  hereditary  syphiHs 
they  present  an  appearance  of 

Fig.  38. — Hutchinson  teeth.  i       j      i       •    >_•  c  1         i.l1 

marked  deviation  irom  health, 
and  are  called  "  Hutchinson  teeth  "  (Fig.  38).  If  they  are 
dwarfed,  too  short  and  too  narrow,  and  if  they  display  a 
single  central  cleft  in  their  free  edge,  then  the  diagnosis  of 
syphilis  is  almost  certain.  If  the  cleft  is  present  and  the 
dwarfing  absent,  or  if  the  peculiar  form  of  dwarfing  be  pres- 
ent without  any  conspicuous  cleft,  the  diagnosis  may  still  be 
made  with  much  confidence.  In  early  infancy  the  diagnosis 
is  made  by  the  snuffles,  broad  nose,  skin-eruptions,  wasted 
look,  sores  at  the  mouth-angles,  tenderness  over  bones,  con- 
dylomata, and  history  of  the  parents.  The  diagnosis  at  a 
later  period  is  made  by  the  existence  of  symmetrical  inter- 
stitial keratitis,  choroiditis,  smooth  base  to  tongue,  deafness 
which  comes  on  without  pain  or  running  from  the  ear,  ossi- 
fying nodes,  white  radiating  scars  about  the  mouth-angles, 
sunken  nose,  natiform  skull,  deformity  of  long  bones,  pain- 
less inflammation  of  epiphyses,  and  Hutchinson  teeth.  It 
must  be  remembered  that  a  child  born  apparently  healthy 
and  presenting  no  secondary  symptoms  may  show  bone-dis- 
ease, keratitis,  or  syphihtic  deafness  at  puberty. 

Treatment. — In  infants  inunctions  are  to  be  used  until  the 
symptoms  disappear,  but  mercury  must  not  be  forced  or  con- 
tinued too  long  after  the  symptoms  are  gone.  There  must  be 
rubbed  into  the  sole  of  each  foot  or  the  palm  of  each  hand  5 
grains  of  mercurial  ointment  every  morning  and  night.  Brodie 
advised  spreading  the  ointment  (in  the  strength  of  sj  to  the 
ounce)  upon  flannel  and  fastening  it  around  the  child's  belly. 
If  the  skin  is  so  tender  that  mercury  must  be  given  by  the 
mouth,  White  and  Hearn  advise  that  gr.  -^  to  gr.  \  of  mer- 
cury with  chalk,  with  i  grain  of  sugar,  be  taken  three  times 
a  day  after  nursing.  If  tertiary  symptoms  appear,  or  in  any 
case  when  the  secondaries  disappear,  give  gr.  ss  to  gr.  j  or 
more  of  iodid  of  potassium  several  times  a  day  in  syrup. 
White  advocates  the  continuance  of  the  mixed  treatment  in- 
termittently until  puberty.  Local  lesions  require  local  treat- 
ment, as  in  the  adult.  A  syphilitic  child  must  be  nursed  by 
its  mother,  as  it  will  poison  a  healthy  nurse.  If  the  baby  has 
a  sore  mouth,  it  must  be  fed  from  a  bottle;  and  if  the  mother 


TUMORS   OR   MORBID    GROWTHS.  209 

cannot  nurse  the  child,  it  must  be  brought  up  on  the  bottle. 
For  the  cachexia  use  cod-liver  oil,  iodid  of  iron,  arsenic,  and 
the  phosphates. 

XVII.  TUMORS   OR   MORBID   GROWTHS. 

Division. — Morbid  growths  are  divided  into  (i)  neo- 
plasms and  (2)  cysts. 

Neoplasms. — A  neoplasm  is  a  pathological  new  growth 
which  tends  to  persist  independently  of  the  structures  in 
which  it  lies,  and  which  performs  no  physiological  function. 
A  hypertrophy  is  differentiated  from  a  tumor  by  the  facts 
that  it  is  a  result  of  increased  physiological  demands  or  of 
local  nutritive  changes,  and  that  it  tends  to  subside  after  the 
withdrawal  of  the  exciting  stimulus.  Further,  a  hypertrophy 
does  not  destroy  the  natural  contour  of  a  part,  while  a  tumor 
does.  Inflammation  has  marked  symptoms :  its  swelling 
does  not  tend  to  persist,  it  terminates  in  resolution,  organ- 
ization, or  suppuration,  and  the  microscope  differentiates  it 
from  tumor.  Inflammation,  too,  has  an  assignable  excit- 
ing cause.  A  new  growth  is  a  mass  of  new  tissue ;  hence 
it  is  improper  to  designate  as  tumors  those  swellings  due 
to  extravasation  of  blood  (as  in  hematocele),  or  of  urine 
(as  in  ruptured  urethra),  to  displacement  of  parts  (as  in 
hernia,  floating  kidney,  or  dislocation  of  the  liver),  or  to 
fluid  distention  of  a  natural  cavity  (as  in  hydrocele  or 
bursitis). 

Classes  of  Tumors. — There  are  two  classes  of  tumors : 
the  first  class  includes  those  derived  from  or  composed  of 
ordinary  connective  tissue  or  of  higher  structures.  These 
all  originate  from  cells  which  are  developed  from  the  meso- 
blast.  There  are  two  groups  of  connective-tissue  tumors  : 
{a)  the  typical,  benign,  or  innocent,  which  find  their  type  in 
the  healthy  adult  human  body  ;  and  (^)  the  atypical  or  malig- 
nant, which  find  no  counterpart  in  the  healthy  adult  human 
body,  but  rather  in  the  immature  connective  tissues  of  the 
embryo. 

The  second  class  of  tumors  includes  those  which  are 
deriv^ed  from  or  composed  of  epithelium :  {a)  the  typical, 
composed  of  adult  epithelium  ;  and  {b)  the  atypical,  com- 
posed of  embryonic  epithelium. 

Mliller's  La^w. — Miiller's  law  is  that  the  constituent  ele- 
ments of  neoplasms  always  have  their  types,  counterparts, 
or  close  imitations  in  the  tissues  of  a  normal  organism^ 
either  embryonic  or  mature. 

14 


2IO  MODERN  SURGERY. 

Virchow's  Law. — Virchow's  law  is  that  the  cells  of  a 
tumor  spring  from  pre-existing  cells  (hence  there  is  no  spe- 
cial tumor-cell  or  cancer-cell). 

The  term  "  heterologous "  is  no  longer  used  to  signify 
that  the  cellular  elements  of  a  tumor  have  no  counterpart 
in  the  healthy  organism,  but  is  employed  to  signify  that  a 
tumor  deviates  from  the  type  of  the  structure  from  which 
it  takes  its  origin  (as  a  chondroma  arising  from  the  parotid 
gland).  Tumors  when  once  formed  almost  invariably  in- 
crease and  persist,  though  occasionally  warts,  exostoses, 
and  fatty  tumors  disappear  spontaneously.  Tumors  may 
ulcerate,  inflame,  slough,  be  infiltrated  with  blood,  or  un- 
dergo mucoid,  calcareous,  or  fatty  degeneration. 

Causes. — The  causes  of  tumors  are  not  positively  recog- 
nized, those  alleged  being  but  theories  varying  in  probability 
and  ingenuity. 

The  inclusion  theory  of  Cohiiheim  supposes  that  more 
embryonic  cells  exist  than  are  needful  to  construct  the  fetal 
tissues,  that  masses  of  them  remain  in  the  tissues,  and  that 
these  may  be  stimulated  later  into  active  growth.  This 
embryonic  hypothesis  seems  to  receive  a  certain  force  from 
the  facts  that  exostoses  do  sometimes  develop  from  portions 
of  unossified  epiphyseal  cartilage,  and  that  tumors  often  arise 
in  regions  where  there  was  a  suppression  of  a  fetal  part, 
closure  of  a  cleft,  or  an  involution  of  epitheHum  (epithelioma 
is  usual  at  muco-cutaneous  junctures).  This  theory,  which 
does  not  explain  the  origin  of  most  neoplasms,  cannot  suc- 
cessfully be  maintained  even  as  a  common  predisposing 
cause. 

Hereditation  is  extremely  doubtful.  S.  W.  Gross  found 
hereditary  influence  by  no  means  frequent  in  cancer  of  the 
breast.  It  is  affirmed  by  some,  denied  by  others,  and  doubted 
by  a  number.  At  most,  hereditary  influence  may  only  pre- 
dispose. Nevertheless,  cases  have  occurred  which  cannot 
be  explained  by  the  term  coincidence.  In  the  celebrated 
"  Middlesex  Hospital  case,"  a  woman  and  five  daughters 
had  cancer  of  the  left  breast.  A.  Pearce  Gould  had 
charge  of  a  woman  for  cancer  of  the  left  breast.  The  mother 
of  this  patient,  the  mother's  two  sisters,  and  two  of  the 
mother's  cousins  had  died  of  cancer. 

Injury  and  inflammation  may  undoubtedly  prove  exciting 
causes.  A  blow  is  not  infrequently  followed  by  sarcoma ; 
the  irritation  of  a  hot  pipe-stem  may  excite  cancer  of  the 
hp ;  the  scratching  of  a  jagged  tooth  may  cause  cancer  of 
the  tongue ;  chimney-sweeps'  cancer  arises  from  the  irrita- 


TUMORS   OR   MORBID    GROWTHS.  211 

tion  of  dirt  in  the  scrotal  creases  ;  and  warts  often  arise  from 
constant  contact  with  acrid  materials. 

Pliysiological  activity  favors  the  development  of  sarcoma, 
and  pliysiological  decline  favors  the  development  of  cancer. 

Parasitic  Liflticnce. — This  theory  does  not  maintain  that 
the  tumor  is  the  parasite,  but  that  it  contains  the  parasite, 
although  Pfeiffer  and  Adamciewicz  did  at  one  time  assert 
that  a  cancer-cell  is  not  a  body-cell,  but  a  parasite  resem- 
bling an  epithelial  cell.  Some  facts  render  a  parasitic  origin 
of  malignant  growths  not  improbable ;  as,  for  instance,  the 
likeness  of  some  tumors  to  infective  granulomata,  their  occa- 
sional secondary  development  in  distant  parts  of  the  body, 
the  resemblance  of  the  secondary  to  the  primary  growths, 
and  the  tenacity  of  their  persistence.  A  parasitic  origin  of 
cancer  is  pointed  to  by  its  geographical  distribution,  the  dis- 
ease being  very  common  in  low  and  marshy  districts  (Havi- 
land). 

Some  surgeons  believe  that  cancer  is  contagious,  but  most 
observers  deny  it.  Guelliott,  of  Rheims,  believes  that  cancer 
is  primarily  a  local  infection.  He  believes  this  because 
Morea  and  Hanau  have  inoculated  it  from  one  animal  to 
another  of  the  same  species,  and  if  this  can  be  brought 
about  experimentally  he  sees  no  reason  why  it  cannot 
happen  accidentally.  This  surgeon  says  that  cancer  is  very 
unequally  distributed,  that  genuine  cancer-centers  and  "  can- 
cer-houses "  exist,  and  that  numerous  cases  of  accidental 
infection  have  occurred.^  Mayet,  of  Lyons,  holds  that  can- 
cer can  be  reproduced  by  grafting  or  by  the  injection  of  can- 
cer-fluid. Graf  could  not  find  "  cancer-houses  "  after  a  care- 
ful search.^  Geissler  claimed  to  have  produced  the  disease 
in  a  dog  by  planting  fragments  of  cancer  in  the  subcutaneous 
tissue  and  vaginal  tissue,  but  Czerny,  Rosenbach,  and  others 
disputed  the  claim.  Hauser  disputes  the  assertion  that  can- 
cer must  be  an  infectious  disease  because  it  is  followed  by 
secondary  growths.  Secondary  growths  in  an  infectious 
disease  are  caused  by  the  bacterium  ;  secondary  growths  in 
cancer  are  caused  by  the  transferrence  of  cells  of  the  growth.^ 
Hauser  says  with  truth  that  the  close  connection  between 
innocent  and  malignant  growths  renders  the  parasite  view 
untenable,  because  to  hold  it  we  would  be  forced  to  believe 
that  every  tumor  has  a  special  parasite  or  that  one  parasite 
may  cause  many  kinds  of  tumor. 

^  Am.  Jour.  Med.  Sci.,  June,  1895. 

'■*  Archiv.  f.  klin.    Chir.,  1895,  1.,  p.  I44. 

^  Hauser,  in  Biolog.  Centralbl.,  Oct.  I,  1895. 


212  MODERN  SURGERY. 

There  seems  to  be  no  doubt  that  autotransference  of  can- 
cer can  occur,  although  it  rarely  does  so.  Sippel  has  re- 
ported a  case  in  which  vaginal  carcinoma  developed  at  the 
point  where  the  vagina  was  in  contact  with  a  pre-existing 
cancer  of  the  portio/  Cornil  has  seen  it  transferred  from 
one  side  of  the  labia  majora  to  the  other,  and  from  one  lip 
to  the  other.  Geissler  was  unable  to  transplant  cancer,  and 
Gratia  also  failed  in  his  attempts.  Duplay  and  Bazin  say 
that  transmissibility  is  possible,  but  only  under  conditions 
which  are  not  practically  realized.  Haviland  believes  strongly 
in  "  cancer-houses."  ^ 

Tillmanns  elaborately  discussed  the  subject  of  cancer  in 
the  Congress  of  1895.  His  conclusions  seem  most  sound 
and  scientific.  He  says  there  is  no  evidence  of  a  bacterial 
origin  of  cancer.  The  parasitic  origin  has  not  been  proved, 
and  protozoa  have  not  certainly  been  found.  Cancer  can  be 
transferred  from  one  part  to  another  part  of  the  same  indi- 
vidual, or  from  one  individual  to  another  of  the  same  species, 
but  never  to  one  of  a  different  species.  It  is  possible  that 
cancer  can  spread  by  contagion ;  this  is  very  rare,  but  can 
happen  (as  when  penile  cancer  is  followed  by  cervix  cancer 
in  a  wife).  Because  it  is  sometimes  possible  to  transfer  can- 
cer, this  does  not  prove  that  the  disease  is  parasitic  or  infec- 
tious ;  it  simply  shows  that  tissue  has  been  successfully 
transplanted. 

Actinomycosis,  long  thought  to  be  a  true  tumor,  is  now 
known  to  arise  from  the  ray-fungus.  There  can  be  no  doubt 
that  changes  in  the  liver  which  practically  constitute  a  new 
growth  can  arise  from  the  growth  of  a  cell  called  by  Darier 
the  "  psorosperm."  A  disease  due  to  psorosperms  is  called 
a  "psorospermosis."  It  is  affirmed  by  some  that  molluscum 
contagiosum,  follicular  keratosis,  cancer,  and  Paget's  disease 
are  due  to  psorosperms.  Some  claim  to  find  the  parasite  in 
all  cases  of  cancer,  while  others  can  find  it  in  only  4  or  5 
per  cent,  of  the  cases. 

Heneage  Gibbes  affirms  ^  that  dilatation  of  the  bile-ducts 
of  a  rabbit's  liver  is  caused  by  the  chronic  irritation  arising 
from  multiplication  of  the  coccidium  oviforme  in  them,  and 
not  in  the  columnar  cells  of  the  bile-ducts,  as  has  been 
stated ;  and,  further,  that  the  large  majority  of  glandular 
cancers  show  nothing  that  can  be  considered  parasitic,  the 
suspicious  appearances  noted  in  some  few  cases  being  due 
to  endogenous  cell-formation.     This  coccidium  oviforme  is 

1  Cent  rail)  I.  f.  Gyndk.,  No.  4,  1894.  ^  Lancet,  April  27,  1894. 

^  The  Aine7-ican  Journal  of  Medical  Sciences,  July,  1893. 


TUMORS   OR   MORBID    GROWTHS.  213 

a  genus  of  the  sporozoa,  class  protozoa,  the  lowest  division 
of  the  animal  kingdom.  To  this  class  belong  the  monera 
and  infusoria. 

Malignant  and  Innocent  or  Benign  Tumors. — 
Malignant  growths  infiltrate  the  tissues  as  they  grow ; 
benign  tumors  only  push  the  tissues  away ;  hence  malignant 
tumors  are  not  thoroughly  encapsuled,  while  innocent  tumors 
are  encapsuled.  Malignant  tumors  grow  rapidly ;  innocent 
tumors  grow  slowly.  Malignant  tumors  become  adherent 
to  the  skin  and  cause  ulceration ;  innocent  tumors  rarely 
adhere  and  rarely  cause  ulceration.  Many  malignant  tumors 
give  rise  to  secondary  growths  in  adjacent  lymphatic  glands 
(cancer,  except  in  the  stomach,  gullet,  and  upper  jaw,  always 
so  tends) ;  sarcoma  does  not  cause  them,  unless  it  be  mel- 
anotic or  unless  it  arises  from  the  testicle  or  tonsil.  Inno- 
cent tumors  never  cause  secondary  lymphatic  involvement, 
although  the  glands  near  the  tumor  may  enlarge  from  acci- 
dental inflammatory  complications.  The  malignant  tumors, 
especially  certain  sarcomata  and  soft  cancers,  may  be  followed 
by  secondary  growths  in  distant  parts  and  various  structures 
(bones,  viscera,  brain,  muscles,  etc.) ;  innocent  tumors  are  not 
followed  by  these  secondary  reproductions,  although  multiple 
fatty  tumors  or  multiple  lymphomata  may  exist.  Malignant 
tumors  destroy  the  general  health  ;  innocent  tumors  do  not. 
Malignant  tumors  tend  to  recur  after  removal ;  innocent  tu- 
mors do  not  if  operation  was  thorough.  The  special  histo- 
logical feature  of  a  malignant  growth  is  the  possession  by 
its  cells  of  a  power  of  reproduction  which  knows  no  limit, 
the  cells  of  the  tumor  living  among  the  body-cells  like  a  par- 
asite, and  invading  and  destroying  the  body-cells. 

Classification. — Tumors  may  be  classified  as  follows  : 

I.  Connective-tissue  tumors. 

1.  Innocent  tumors,  or  those  composed  of  mature  con- 

nectiv^e  tissue : 
Lipomata^  or  fatty  tumors  ;  fibromata,  or  fibrous  tu- 
mors ;  cliondrouiata,  or  cartilaginous  tumors  ;  ostco- 
inata,  or  bony  tumors ;  odontomata,  or  tooth-tumors ; 
inyxomata,  or  mucous  tumors ;  myomata,  or  muscle- 
tumors  ;  neuromata,  or  tumors  upon  nerves ;  aiigcio- 
mata,  or  tumors  formed  of  blood-vessels;  lympJian- 
gciomata,  or  tumors  formed  of  lymphatic  vessels ; 
and  lympJwmata,  or  tumors  of  lymphatic  glands. 

2.  Malignant  tumors,  or  those  composed  of  embryonic 

connective  tissue : 
Sarcomata. 


214  MODERN  SURGERY. 

II.  Epithelial  tumors. 

1.  Innocent  tumors,  or  those  composed  of  mature  epi- 

thelial tissue : 
Adenomata,  or  tumors  whose  type  is  a  secreting  gland ; 
and  papillomata,  or  tumors  whose  type  is  found  in 
the  papillae  of  skin  and  mucous  membranes. 

2.  Malignant  tumors,  or  those  composed  of  embryonic 

epithelial  tissue : 
Carcinomata,  or  cancers. 

I.  Innocent  Connective-tissue  Tumors. — The  growths 
mimic  or  imitate  some  connective  tissue  or  higher  tissue  of 
the  mature  and  healthy  organism. 

I/ipomata  are  congenital  or  acquired  tumors  composed 
of  fat  contained  in  the  cells  of  connective  tissue,  which  cells 
are  bound  together  by  fibers.  If  the  fibers  are  excessively 
abundant,  the  growth  is  spoken  of  as  a  "  fibro-fatty  tumor." 
A  fatty  tumor  has  a  distinct  capsule,  tightly  adherent  to  sur- 
rounding parts,  but  loosely  attached  to  the  tumor;  hence 
enucleation  is  easy.  Fibrous  trabeculse  run  from  the  capsule 
of  a  subcutaneous  lipoma  to  the  skin ;  hence  movement  of 
the  integument  over  the  tumor  or  of  the  tumor  itself  causes 
dimpling  of  the  skin.  Lipomata  are  most  frequent  in  middle 
life,  and  their  commonest  situations  are  in  the  subcutaneous 
tissues  of  the  back  or  of  the  dorsal  surfaces  of  the  Hmbs ; 
they  usually  occur  singly,  but  may  be  multiple  and  some- 
times symmetrical.  Senn  has  described  the  case  of  a  woman 
who  had  a  fatty  turnor  in  each  axilla.  A  lipoma  is  soft, 
doughy,  mobile,  lobulated,  of  uniform  consistence,  and  may 
give  on  tapping  a  tremor  or  pseudo-fluctuation.  It  may 
grow  to  an  enormous  size  (in  Rhodius's  case  it  weighed  sixty 
pounds),  and  the  growth  may  be  progressive  or  may  be  at 
times  stationary  and  at  other  times  active.  The  skin  over  a 
fatty  tumor  sometimes  atrophies  or  even  ulcerates ;  the  tumor 
itself  may  inflame  or  partly  calcify.  When  a  lipoma  has  once 
inflamed,  it  becomes  immovable.  The  commonest  situation 
for  lipomata  is  in  the  subcutaneous  layer  of  fat.  Subcutane- 
ous lipoma  of  the  palm  of  the  hand  or  sole  of  the  foot  re- 
sembles a  compound  ganglion,  and  it  is  apt  to  be  congenital. 
Lipomata  of  the  head  and  face  are  rare.  In  the  subcutane- 
ous tissues  of  the  groins,  neck,  pubes,  axillae,  or  scrotum  a 
mass  of  fat  may  form,  unlimited  by  a  capsule  and  known  as 
a  "  diffuse  lipoma."  A  nevo-lipoma  is  a  nevus  with  much 
fibro-fatty  tissue.  A  very  vascular  fatty  tumor  is  called 
lipoma  telangiectodes.  If  the  tumor  stroma  contains  large 
veins,  the  growth  is  called  a  cavernous  lipoma.     A  tumor 


TUMORS   OR   MORBID    GROWTHS.  215 

containing  much  blood  can  be  diminished  in  size  by  pressure. 
Fatty  tumors  may  arise  in  the  subserous  tissue,  and  when 
arising  in  either  the  femoral  or  inguinal  canals  or  the  linea 
alba  they  resemble  omental  hernia  and  are  spoken  of  as 
"  fat-hernia."  In  the  retroperitoneal  tissues  enormous  fibro- 
fatty  tumors  occasionally  grow,  and  these  neoplasms  tend  to 
become  sarcomatous.  Lipomata  may  arise  from  beneath 
synovial  membranes  and  will  project  into  the  joints,  being 
still  covered  by  synovial  membrane.  Fatty  tumors  occasion- 
ally arise  in  submucous  tissues,  between  or  in  muscles,  from 
periosteum,  and  from  the  meninges  of  the  spinal  cord  (J. 
Bland  Sutton).  A  fatty  tumor  may  undergo  metamorpho- 
sis. The  stroma  may  be  attacked  by  a  myxomatous  process 
or  a  calcareous  degeneration.  The  fat-cells  themselves  may 
become  calcareous.     Oil-cysts  sometimes  form  (Senn). 

Treatment. — A  single  subcutaneous  lipoma  is  to  be  re- 
moved. Open  the  capsule,  tear  out  or  dissect  out  the  mass, 
and  always  drain  for  twenty-four  hours,  as  butyric  fermenta- 
tion will  be  apt  to  occur,  and  necrosis  of  small  particles  of 
fat  predisposes  to  infection.  Multiple  subcutaneous  lipomata, 
if  very  numerous,  should  not  be  interfered  with  unless 
troublesome  because  of  their  size  or  situation,  when  they 
should  be  removed.  Diffuse  lipomata  cannot  be  removed 
entirely,  and  operation  is  useless.  Liquor  potassae  has  been 
recommended  to  limit  growth  ;  it  may  be  taken  internally 
for  a  considerable  time,  but  it  seems  to  be  useless.  Subperi- 
toneal lipomata  are  rarely  diagnosticated  until  the  belly  has 
been  opened  or  the  growth  has  been  removed. 

Fibromata  are  tumors  composed  of  wavy  fibrous  bundles 
of  adult  fibrous  tissue.  Senn  tells  us  that  benign  endothe- 
lial tumors  belong  under  this  head.  A  fibroma  has  no  dis- 
tinct capsule,  though  surrounding  tissues  are  so  compressed 
as  to  simulate  a  capsule.  Fibromata  are  occasionally  con- 
genital, are  most  usual  in  young  adults,  but  they  may  occur 
at  any  period  of  life,  in  any  part  of  the  body  containing  con- 
nective tissue,  and  are  hard  and  movable.  Pure  fibromata, 
which  are  rare,  are  generally  solitary,  grow  slowly,  are  of 
uniform  consistence,  and  have  not  much  circulation.  Soft 
fibromata  grow  more  rapidly  than  the  hard,  may  become 
quite  large,  are  apt  to  have  distinct  pedicles,  and  arise  gen- 
erally from  the  skin  of  the  scrotum,  labia,  uterus,  and  on  the 
inner  surface  of  the  arm  or  the  thigh,  and  from  the  belly- wall 
of  a  pregnant  woman.  There  may  be  several  of  these  growths 
(the  author  has  seen  seven  on  one  person).  Hard  fibromata 
grow  slowly ;  they  may  form  upon  nerves,  they  may  arise  in 


2l6  MODERN  SURGERY. 

the  mammary  gland,  they  may  develop  in  the  lobe  of  the  ear 
in  a  person  who  wears  earrings,  and  they  may  spring  from 
various  fibrous  membranes,  from  the  periosteum  of  the  nasal 
bones  (fibrous  polypi),  and  from  the  gums  (fibrous  epulides). 
Fibromata  may  become  cystic,  calcareous,  osseous,  colloid, 
or  sarcomatous,  and  may  become  inflamed,  ulcerated,  or  even 
gangrenous. 

A  painful  siibciitaneoiis  tubercle,  which  is  a  form  of  fibroma 
commonest  in  females,  arises  in  the  subcutaneous  cellular 
tissue,  usually  of  the  extremities.  It  is  firm,  very  tender, 
movable,  rarely  larger  than  a  pea,  and  the  skin  over  it  seems 
healthy.  \"iolent  pain  occurs  in  parox}-sms  and  radiates  over 
a  considerable  area  of  which  the  tubercle  is  the  center.  These 
paroxysms  may  occur  only  once  in  many  days  or  many  times 
in  one  day.  Pain  may  always  be  dev^eloped  by  pressure,  and 
may  be  linked  with  spasm.  Nerve-fibrillae  were  never  found 
in  these  tubercles  until  a  recent  period. 

A  mole  is  a  congenital  fibroma  of  the  skin  (Senn).  It  is 
rounded  or  flat,  is  usually  pigmented,  is  apt  to  have  hairs 
growing  from  it,  and  varies  in  size  from  a  pin's  head  to  several 
inches  in  diameter.  The  tumor  rarely  grows  after  the  thir- 
teenth or  fourteenth  year.  A  mole  may  become  malignant,  a 
melanotic  carcinoma  may  arise  from  its  epithelial  structures, 
a  melanotic  sarcoma  from  its  connective-tissue  elements. 

Fibrous  epulis  is  a  fibroma  arising  from  the  gums  or  peri- 
odontal membrane  (J.  Bland  Sutton)  in  connection  with  a  cari- 
ous tooth  or  retained  snag ;  it  is  covered  by  mucous  mem- 
brane, grows  slowly,  may  attain  a  large  size,  and  sometimes 
has  a  stem,  but  is  more  often  sessile.  It  may  undergo  myx- 
omatous change  or  may  become  sarcomatous. 

Fibrous  tumors  may  arise  from  the  ovar}-,  the  intestine, 
and  the  lan,-nx.  Pure  fibromata  of  the  uterus  are  ver>^  rare, 
but  fibromyomata  are  ver}*  common  (see  Myomata,  p.  222); 
hence  the  term  "  uterine  fibroid"  should  be  abandoned. 

Molluscuni  fibrosinn  is  an  overgrowth  of  the  fibrous  tissue 
of  both  skin  and  subcutaneous  structure.  Senn  excludes 
this  form  of  growth  from  consideration  with  fibromata,  be- 
cause of  its  infective  origin.  It  may  be  limited  or  widely  ex- 
tended ;  it  may  appear  as  an  infinite  number  of  nodules  scat- 
tered over  the  entire  body  or  as  hanging  folds  of  fibrous 
tissue  in  certain  areas.  Keloid  is  a  hard  fibrous  vascular 
growth,  with  a  broad  base,  arising  in  scar-tissue  ;  it  is  crossed 
by  pink,  white,  or  discolored  ridges,  and  is  named  from  a 
fancied  likeness  to  the  crab.  It  is  more  common  in  negroes 
than  in  whites,  and  is  most  frequent  in  the  cicatrices  of  burns, 


TUMORS   OR   MORBID    GROWTHS.  21/ 

though  it  may  arise  in  the  scar  of  any  injury,  as  the  scar 
from  piercing  the  ears,  and  in  the  scars  of  syphiHtic  lesions, 
tubercular  processes,  small-pox,  or  vaccination.  It  is  rare 
in  early  childhood  and  in  old  age.  It  grows  slowly,  lasts 
for  many  years,  and  may  eventually  undergo  involution  and 
disappear. 

iMoj'pIua,  or  spontaneous  keloid,  is  a  name  used  to  desig- 
nate a  growth  of  this  description  which  does  not  arise  from 
a  scar;  but  it  seems  certain  that  scar-tissue  was  present, 
though  possibly  in  small  amount  from  trivial  injury. 

Fibrous  and  papillomatous  growths  of  a  serous  membrane 
may  occur.  They  are  covered  with  endothelium.  Such  a 
growth  of  the  choroid  plexus  calcifies  early  and  constitutes 
a  psammoma.  Cholesteatoma  is  a  fibrous  growth  covered 
with  endothelium  and  containing  layers  of  crystalline  fat.  It 
occurs  especially  in  the  pia  mater,  and  is  called  a  pearl 
tumor. 

Treatment.  —  Enucleate  fibromata  when  in  accessible 
regions;  do  not  let  them  remain,  as  any  fibrous  tumor 
may  become  a  sarcoma.  Epulis  requires  the  cutting 
away  of  the  entire  mass,  the  removal  of  the  related  snag 
or  carious  tooth,  and  sometimes  the  biting  away  of  a  por- 
tion of  the  alveolus  with  rongeur  forceps.  Keloid  should 
not  be  operated  upon  :  it  will  only  return,  and  will  also 
recur  in  the  stitch-holes.  Trust  to  time  for  inv^olution, 
or  use  pressure  with  flexible  collodion,  by  which  method 
J.  M.  DaCosta  cured  a  case  following  small-pox.  The 
administration  of  thyroid  extract  may  be  of  benefit  (a  gr.  v 
tablet  3  or  4  times  a  day).  This  drug  must  be  given  cau- 
tioush\  as  it  may  cause  attacks  characterized  by  fever, 
dyspnea,  and  rapid  pulse.  A  mole  ought  to  be  excised, 
because,  if  allowed  to   remain,  it  may  become  malignant. 

Chondromata  (enchondromata)  are  tumors  formed  either 
of  hyaline  cartilage,  of  fibrocartilage,  or  of  both.  Chondro- 
mata are  apt  to  occur  in  certain  glands,  in  the  long  bones, 
the  pelvis,  the  rib-cartilages,  and  the  bones  of  the  hands  or 
feet,  and  often  spring  from  unossified  portions  of  epiphyseal 
cartilage.  They  may  be  single  or  multiple,  are  often  nodu- 
lated, and  are  most  commonly  met  with  in  the  young. 
They  have  distinct  adherent  capsules ;  they  grow  slowly, 
progressively  hollowing  out  the  bones  by  pressure ;  they 
cause  no  pain  ;  they  impart  a  sensation  of  firmness  to  the 
touch,  unless  mucoid  degeneration  forms  zones  of  softness 
or  fluctuation  ;  they  are  inelastic,  smooth  or  nodular,  im- 
movable, and  often  ossify.     Chondromata  may  grow  to  an 


2l8  MODERN  SURGERY. 

enormous  size.  A  chondroma  of  the  parotid  gland  or  testi- 
cle always  contains  sarcomatous  elements,  and  any  chon- 
droma may  become  a  sarcoma.  Chondromata  are  notably 
frequent  in  persons  who  had  rickets  in  early  life.  Ecclion- 
droses,  which  are  "  small  local  overgrowths  of  cartilage " 
(J.  Bland  Sutton),  arise  from  articular  cartilages,  especially  of 
the  knee-joint,  and  from  the  cartilages  of  the  larynx  and 
nose.  Loose  or  floating  cartilages  in  the  joints  may  be 
broken-off  ecchondroses  or  portions  of  hyaline  cartilage 
which  are  entirely  loose  or  are  held  by  a  narrow  stalk,  and 
which  arise  by  chondrification  of  villous  processes  of  the 
synovial  membrane ;  only  one  or  vast  numbers  may  exist ; 
one  joint  may  be  involved,  or  several ;  they  may  produce 
no  symptoms,  but  usually  produce  from  time  to  time  violent 
pain  and  immobility  by  acting  as  a  joint-wedge. 

Treatment. — Remove  chondromata  whenever  possible, 
for,  if  allowed  to  remain  undisturbed,  they  are  apt  to  resent 
this  hospitality  by  becoming  sarcomatous.  Incise  the  cap- 
sule and  take  away  the  growth,  using  chisels  and  gouges 
if  necessary.  Incomplete  removal  means  inevitable  recur- 
rence. Amputation  is  very  rarely  demanded.  Loose  bodies 
in  the  joints,  if  productive  of  much  annoyance,  are  to  be 
removed,  the  joint  being  opened  with  the  strictest  antiseptic 
care. 

Osteomata. — J.  Bland  Sutton  says  that  osteomata  are 
ossifying  chondromata.  Compact  osteomata,  which  are  iden- 
tical in  structure  with  the  compact  tissue  of  bone,  occur  in 
the  frontal  sinus,  mastoid  process,  external  auditory  meatus, 
and  in  other  regions  in  those  beyond  middle  life ;  they  are 
small,  capped  with  cartilage,  smooth,  round,  with  small, 
occasionally  cartilaginous  bases,  and  are  densely  hard. 

Cancellous  osteomata,  which  comprise  the  great  majority 
of  bone-tumors,  are  similar  in  structure  to  cancellous  bone. 
They  spring  from  and  are  crusted  with  cartilage  ;  they  may 
have  fibrous  capsules,  and  are  often  movable  when  recent, 
but  soon  become  fixed  ;  they  have  broad  bases,  are  angled, 
nodular,  firm  (but  not  so  hard  as  are  the  compact  osteomata), 
painless  except  when  pressed,  occur  particularly  at  the  ends 
of  long  bones,  may  grow  to  large  size,  and  are  commonest 
in  youth.  Osteomata  near  joints  become  overlaid  by  bursae 
which  in  rare  instances  communicate  with  their  related 
joints. 

The  term  exostosis  has  been  used  as  being  synonymous 
with  osteoma,  but  wrongly  so,  as  an  exostosis  is  an  irregu- 
lar, local,  bony   growth   which   does   not   tend  to   progress 


TUMORS   OR   MORBID    GROWTHS.  219 

beyond  a  certain  point,  and  which  is  hence  not  a  tumor. 
A  true  exostosis  is  seen  in  the  ossification  of  a  tendon-inser- 
tion, in  a  limited  growth  from  the  maxillary  bones,  and  in  a 
local  growth  from  the  last  phalanx  of  the  big  toe,  which 
growth  is  known  as  a  "  sub-ungual  exostosis."  Exostoses 
of  the  retrocalcaneal  bursa  occasionally  arise  when  this  bursa 
is  inflamed.  Inflammation  of  this  bursa  is  known  as  Achillo- 
dynia  or  Albert's  disease.  The  bony  masses  sometimes  found 
in  the  brain,  lungs,  testicle,  various  glands,  and  tumors  are 
not  true  osteomata. 

Treatment. — Osteomata  which  are  nonproductive  of  pain 
or  trouble  do  not  demand  removal.  If  they  produce  pain 
by  pressure,  if  they  press  upon  important  structures,  if  they 
cause  annoying  deformities,  or  if  they  grow  rapidly,  then 
remove  them  by  means  of  chisels,  gouges,  or  by  the  sur- 
gical engine.  Exostosis  of  the  toe  should  always  be  re- 
moved, to  do  which  the  nail  should  be  split  and  part  of  it 
taken  away,  and  the  bony  mass  be  gouged  away  or  be  cut 
off  with  forceps. 

Odontomata '  are  tumors  composed  of  tooth-tissue  and 
springing  from  the  germs  of  teeth  or  from  developing  teeth. 
J.  Bland  Sutton  divides  them  into  (i)  those  springing  from 
the  follicle ;  (2)  those  springing  from  the  papilla ;  and  (3) 
those  springing  from  the  whole  germ. 

Epithelial  odontoraes,  or  multilocular  cystic  tumors, 
arise  from  the  follicle,  occur  oftenest  in  the  lower  jaw,  dilate 
the  bone,  have  capsules,  and  are  made  up  of  masses  of  cysts 
which  are  filled  with  brown  fluid.  These  cysts  are  met 
with  most  frequently  before  the  age  of  twenty.  Follicular 
odoutoiiics,  or  dcntigcrous  cysts,  oftenest  spring  from  the 
follicles  of  the  permanent  molars.  In  a  dentigerous  cyst 
there  exists  an  expanded  follicle  which  distends  the  bone, 
the  follicle  being  filled  with  thick  fluid  and  containing  a 
portion  of  a  tooth.  K  fibrous  odontojiic  is  due  to  thickening 
of  the  tooth-sac,  thus  preventing  eruption  of  the  tooth ; 
fibrous  odontomes  are  usually  multiple,  and  are  apt  to  occur 
in  rickety  children.  A  ceinciitoinc  is  due  to  enlargement, 
thickening,  and  ossification  of  the  capsule,  the  developing 
tooth  being  encased  in  cement.  A  compound  follicular  odon- 
tomc  is  due  to  ossification  of  portions  only  of  an  enlarged 
and  thickened  capsule,  and  the  tumor  contains  bits  of 
cementum,  portions  of  dentine,  or  small  misshapen  teeth. 
A  radicidar  odontonie  springs  from  the  papilla  and  arises 

^  This  section  is  abridged  from  J.  Bland  Sutton's  stril^ing  chapter  upon  odon- 
tomes in  his  recent  work  on  Tumors. 


220  MODERN  SURGERY. 

after  the  crown  of  the  tooth  is  formed  and  while  the  roots 
are  forming ;  hence  it  contains  dentine  and  cement,  but  no 
enamel.  Composite  odontomes  are  formed  of  irregular,  shape- 
less masses  of  dentine,  cement,  and  enamel.  All  the  above 
forms  occur  in  man.  They  present  themselves  as  hard 
tumors  associated  with  teeth  or  in  an  area  where  teeth  have 
not  erupted.  They  may  distend  the  jaw.  Occasionally  an 
odontome  simulates  necrosis ;  it  is  surrounded  by  pus,  and  a 
sinus  forms. 

Treatment. — The  diagnosis  is  scarcely  ever  made  until 
after  incision  ;  hence,  be  in  no  haste  to  excise  large  por- 
tions of  bone  for  a  doubtful  growth ;  incise  first  and  see  if 
it  be  an  odontome,  which  requires  only  the  removal  of  an 
implicated  tooth,  curetting  with  a  sharp  spoon,  and  packing 
with  iodoform  gauze. 

Myxomata  are  tumors  composed  of  mucous  tissue. 
They  are  rare  as  independent  growths,  although  myxo- 
matous change  is  frequent  in  the  stroma  of  other  tumors. 
The  tissue  type  of  these  tumors  is  found  in  the  vitreous 
humor  of  the  eye  and  in  the  perivascular  tissues  of  the 
umbilical  cord  (Wharton's  jelly).  Bowlby  states  that  myxo- 
mata are  in  reality  soft  fibromata  whose  intercellular  sub- 
stance has  been  replaced  by  mucin.  The  myxomatous  state 
may  be  a  stage  in  the  formation  of  a  fibroma,  a  stroma  not 
having  developed.  Myxomata  may  result  from  myxomatous 
degeneration  of  cartilage,  of  muscle,  or  of  fibrous  tissue. 
These  tumors  are  soft,  elastic,  usually  pedunculated,  tremu- 
lous, and  vibratory.  The  stroma  is  very  delicate  and  carries 
minute  blood-vessels.  Cutting  into  them  causes  a  straw- 
colored,  clear  jelly  to  exude ;  they  grow  slowly,  are  encap- 
suled,  have  but  little  circulation,  and  their  diagnosis  may  be 
impossible  before  removal.  Some  pathologists  place  myxo- 
mata among  the  malignant  tumors,  but  most  consider  them 
as  benign  tumors,  though  they  tend  strongly  to  become 
sarcomatous  (myxosarcomata).  A  sarcoma  may  undergo 
myxomatous  degeneration. 

Myxomata  may  arise  from  the  skin ;  from  the  mucous 
membrane  of  the  nose,  the  frontal  sinus,  the  antrum,  the 
womb,  auditor}^  meatus,  and  the  tympanum  (gelatinous 
polyps) ;  from  the  parotid  and  mammary  glands ;  from  the 
subcutaneous  tissue,  the  nerve-sheaths,  the  intermuscular 
septi,  the  rectum,  and  the  bladder  (polyps).  They  may  be 
congenital,  but  occur  most  often  in  young  adults,  as  a  result 
of  inflammation.  A  sudden  increase  of  growth  indicates  be- 
ginning malignancy  (sarcomatous  change).     When  a  tumor 


Ti'MORS   OR   MORE  ID    GROWTHS.  221 

begins  to  undergo  myxomatous  transformation  we  give  to  it 
a  compound  name  ;  for  instance,  chondromyxoma,  fibro- 
myxoma,  etc. 

Nasal  polypi  grow  from  the  mucous  membrane  over  the 
turbinated  bones  ;  they  are  soft  and  jelly-like,  of  a  grayish 
color,  and  have  stems  or  pedicles ;  they  may  be  seen  through 
the  anterior  nares.  may  project  behind  the  veil  of  the  palate, 
and  may  bulge  out  from  the  passages  of  the  nose  ;  the}'  may 
be,  and  usually  are,  multiple ;  they  may  be  present  in  one  nasal 
fossa  or  in  both  ;  and  they  occur  most  commonly  in  young 
adults. 

Hydatid  moles  of  pregnancy  are  due  to  myxomatous 
changes  in  the  chorion. 

Treatment. — In  treating  myxomata,  remove  them  prompt- 
ly and  thoroughly,  because  of  the  danger  of  sarcomatous 
change.  Nasal  polyps  may  usually  be  twisted  off  or  be  re- 
moved by  the  wire  snare  or  galvano-cautery ;  but  occasion- 
ally extensive  operations  are  required  for  their  removal.  A 
soft  myxoma  breaks  up  when  remov^al  is  attempted,  and  the 
base  must  be  cauterized. 

I/jntnphomata  are  tumors  composed  of  lymphatic-gland 
structure,  and  are  due  to  multiplication  of  pre-existing  ade- 
noid tissue  (idiopathic  lymplipmata).  Lymphomata  are  most 
frequently  encountered  in  the  neck  and  axillae,  but  are  not 
unusualh'  met  with  in  the  groins.  One  gland  or  many  may 
be  involved  ;  they  grow  rapidly  and  attain  a  large  size ;  they 
are  painless,  are  encapsuled,  and  are  freely  movable  beneath 
the  skin ;  they  do  not  infiltrate  surrounding  tissues,  and  pre- 
sent no  thickening  from  inflammation  ;  they  are  commonest 
between  the  ages  of  twenty  and  thirty-five,  but  they  may 
occur  in  early  life.  Gross  states  that  the  enlargement  usually 
begins  upon  one  side  of  the  neck,  gland  after  gland  being 
successively  attacked ;  in  from  four  to  eighteen  months  the 
glands  of  both  sides  of  the  neck,  the  axillae,  the  bronchi,  and 
the  mesentery  become  involved,  the  patient's  health  fails,  and 
death  soon  ensues.  These  tumors  are  said  not  to  be  malig- 
nant, but  certain  it  is  that  they  tend  to  recur  after  removal. 
It  is  impossible  to  distinctly  separate  this  disease  from  lymph- 
adenoma  :  they  probably  are  related,  or  possibly  are  iden- 
tical. Sarcoma  of  a  lymphatic  gland  arises  later  in  life  than 
does  lymphoma ;  it  infiltrates  surrounding  structure,  render- 
ing the  growth  immovable,  and  implicates  the  related  glands 
gluing  them  together ;  the  tumor  is  painful  and  the  skin 
ulcerates.  Lymphoma  differs  from  tubercular  lymphadenitis 
in  many  ways.     It  originates  in  an  apparently  healthy  person ; 


222  MODERN  SURGERY. 

it  has  no  tendency  to  caseation  or  suppuration ;  the  growths 
do  not  infiltrate,  but  remain  movable  ;  and  the  overlying  skin 
retains  a  healthy  appearance. 

Treatment. — If  possible,  entirely  extirpate  a  lymphoma; 
but  if  complete  removal  is  impossible,  perform  no  operation. 
In  inoperable  cases  order  cod-liver  oil  and  nutritious  diet, 
insist  on  open-air  exercise,  employ  inunctions  of  ichthyol, 
give  courses  of  arsenic  in  advancing  doses,  and  from  time  to 
time  administer  iodid  of  potassium  and  iron  in  some  form. 
Fowler's  solution  as  an  injection  into  the  growth  finds  some 
advocates. 

Myomata  are  tumors  composed  of  unstriped  muscle-fiber 
mixed  often  with  fibrous  tissue  (leiomyomata).  Tumors  com- 
posed of  striated  muscle-fiber  (rhabdomyomata)  are  very  rare 
and  are  always  sarcomatous.  Leiomyomata  are  found  in 
the  womb,  in  the  prostate  gland,  in  the  walls  of  the  gullet, 
vagina,  stomach,  bladder,  and  bowel,  in  the  broad  ligament, 
ovary,  and  round  ligament,  in  the  scrotum,  and  in  the  skin. 
Myomata  usually  begin  during  or  after  middle  age  ;  they  are 
encapsuled,  they  grow  slowly,  they  are  firm  and  hard,  and 
they  produce  annoyance  by  their  size  and  weight  or  by  ob- 
structing a  viscus  or  channel.  A  leiomyoma  of  the  posterior 
and  middle  of  the  prostate  forms  "  a  middle  lobe." 

The  so-called  "  uterine  fibroid"  is  a  myoma  or  fibromyoma. 
Uterine  myomata  may  originate  within  the  walls  of  the  womb 
(intramural  myomata),  from  the  muscular  structure  of  the 
mucous  lining  (submucous  myomata),  or  from  the  muscular 
tissue  of  the  serous  covering  (subserous  myomata).  Intra- 
mural uterine  myomata  may  be  single  or  be  multiple  and 
may  grow  to  an  enormous  size.  Submucous  myomata  pro- 
ject into  the  cavity  of  the  womb  (fleshy  polyps).  Submucous 
myomata  distend  the  uterus  and  are  often  accompanied  by 
menorrhagia  or  metrorrhagia ;  they  may  project  into  the 
vagina.  In  some  rare  cases  the  projecting  tumor  is  detached 
by  nature  and  the  patient  is  cured  ;  in  other  cases  the  myoma 
becomes  gangrenous.  This  form  of  tumor  may  produce  in- 
version of  the  fundus  of  the  womb.  Subserous  uterine  myo- 
mata cause  trouble  only  by  the  inconvenience  of  weight  or 
the  discomfort  of  pressure.  Uterine  myomata  may  undergo 
fatty,  calcareous,  or  myxomatous  change,  and  may  be  infected 
by  septic  organisms  as  a  result  of  the  use  of  a  uterine  sound 
or  of  infection  of  the  pedicle  after  oophorectomy.  Infection 
of  a  uterine  myoma  causes  great  enlargement,  elevated  tem- 
perature, sweats,  and  exhaustion.  Uterine  myomata,  which 
are  commonest  in  single  women  (J.  Bland  Sutton),  arise  most 


TUMOFS   OR   MORBID    GROWTHS.  223 

frequently  between  the  ages  of  twenty-five  and  forty-five. 
They  may  never  produce  any  symptoms  ;  some,  by  enlarg- 
ing until  they  ascend  above  the  pelvic  brim,  produce  abdom- 
inal distention ;  some  become  jammed  or  impacted  in  the 
pelvis,  and  produce  by  pressure  retention  of  urine,  obstruc- 
tion to  passage  of  feces,  or  hydronephrosis.  Impaction  may 
occur  temporarily  at  each  menstrual  period.  Many  myomata 
produce  uterine  hemorrhage  ;  some  cause  retroversion  of  the 
womb  ;  some  protrude  from  the  cervical  canal ;  some  are  so 
large  that  they  cause  disastrous  pressure  upon  the  colon  (ob- 
struction), upon  the  iliac  veins  (intense  edema),  or  upon  the 
ureters  (hydronephrosis).  Uterine  myomata  usually  shrink 
after  the  menopause.  Pregnancy  in  a  myomatous  womb 
usually  ends  in  abortion. 

The  symptoms  of  myomata  of  the  alimentary  canal  are 
similar  to  or  identical  with  the  symptoms  of  malignant 
growths.  Myomata  of  the  skin  are  rare  growths  ;  they  are 
encapsuled,  firm  or  elastic,  and  painless. 

Treatment. — Cutaneous  myomata  are  removed  in  the  same 
manner  as  fibrous  tumors.  Uterine  myomata  are  treated  by 
rest  and  the  administration  of  ergot,  barium  chlorid,  and  di- 
lute sulphuric  acid.  If  this  treatment  fails  to  arrest  serious 
bleeding  due  to  a  fleshy  polyp,  dilate  the  cervical  canal  and 
remove  the  growth.  If  there  be  dangerous  bleeding  in  a 
woman  who  has  some  years  to  wait  for  the  menopause  and 
who  has  not  a  removable  polyp  as  the  cause,  perform 
oophorectomy  in  order  to  bring  on  an  artificial  menopause. 
When  a  myoma  becomes  impacted  at  each  menstrual  period 
remove  the  ovaries  and  Fallopian  tubes.  Hysterectomy  is 
indicated  for  some  very  large  tumors,  for  tumors  that  grow 
after  the  menopause,  and  for  infected  myomata.  If  the  abdo- 
men be  opened  to  perform  oophorectomy,  and  the  tubes  and 
ovaries  are  found  so  implicated  in  the  growth  that  they  can- 
not be  removed  completely,  or  the  broad  ligament  is  found 
so  drawn  out  that  a  safe  pedicle  cannot  be  secured,  perform 
a  hysterectomy.^  A  recent  suggestion  for  the  shrinkage  of 
uterine  myomata  is  to  ligate  both  the  uterine  and  ovarian 
arteries.  If  a  myoma  of  the  prostate  cause  severe  obstruc- 
tion, effect  a  suprapubic  cystotomy  and  remove  the  major 
portion  of  the  enlarged  gland  ;  or  make  both  a  suprapubic 
and  a  perineal  opening,  push  the  gland  into  the  perineum 
and  shell  it  out  with  the  finger,  or  perform  White's  operation 
(double  castration). 

1  See  J.  Pjland  Sutton's  admirable  article  on  "  Uterine  Myomata  "  in  his  work 
on  Tumors. 


224  MODERN  SURGERY. 

Neuromata. — A  true  neuroma  springs  from  nerve-tissue 
(brain,  cord,  or  nerve-trunks) ;  it  is  composed  of  medullated 
or  non-medullated  nerve-fibers  which  form  a  plexus  or  net- 
work and  which  are  not  continuous  with  the  fibers  of  the 
nerve-trunk  or  other  area  from  which  the  tumor  grows. 
True  neuromata,  which  are  rare  growths,  arise  during  mid- 
dle life ;  they  are  small  in  size,  are  due  to  injury  or  hered- 
itary tendency,  and  they  may  be  single  or  multiple.  There 
is  usually  around  the  tumor,  rather  than  in  it,  severe  neu- 
ralgic pain,  which  is  greatly  intensified  by  dampness,  by 
blows,  or  by  rough  handling.  The  parts  below  a  neuroma 
are  cold,  swollen,  often  anesthetic,  and  frequently  present 
motor  paralysis  or  trophic  disorder.  A  false  neuroma  or 
neurofibroma  is  a  tumor  growing  from  a  nerve-sheath,  and 
is  identical  in  structure  with  the  sheath.  False  neuromata 
may  be  single,  but  they  are  often  multiple ;  they  may  be  as 
small  as  peas  or  as  large  as  oranges ;  they  are  smooth  and 
movable,  and  may  cause  great  pain  or  may  only  hurt  when 
pressed  or  struck ;  they  may  spring  from  roots,  trunks,  or 
branches,  and  they  may  be  hnked  with  the  disease  known 
as  "  molluscum  fibrosum."  In  plexiform  neuroma  some 
branches  of  a  nerve  enlarge  and  lengthen  like  an  artery 
in  a  cirsoid  aneurysm ;  the  mass  feels  like  beads  or  like 
a  bag  of  worms ;  it  is  mobile,  and  no  pain  is  felt  on  moving 
it ;  and  it  is  generally  congenital.  In  plexiform  neuroma  the 
nerve-sheath  undergoes  myxomatous  change.  Malignant 
neuroma  means  primary  sarcoma  of  a  nerve-sheath,  though 
any  neuroma  may  become  sarcomatous. 

Traumatic  neuromata  are  occasionally  well  exhibited  after 
nerve-section  or  amputation.  On  nerve-section  the  distal 
end  shrinks  and  atrophies,  the  proximal  end  enlarges  and 
becomes  bulbous.  These  traumatic  neuromata  are  composed 
of  fibrous  tissue  which  contains  nerve-fibres ;  they  are  usu- 
ally, but  not  always,  painful  on  pressure  or  during  damp- 
ness, and  they  are  commonest  in  stumps  which  did  not  heal 
by  first  intention.  Painful  subcutaneous  tubercle  is  consid- 
ered under  the  head  of  Fibromata.  In  performing  an  ampu- 
tation cut  the  nerves  high  up,  and  thus  keep  them  out  of 
the  scar  and  prevent  a  tender  stump.  A  tender  stump  may 
be  simple,  due  to  anchoring  the  nerve  in  a  scar,  and  thus 
preventing  gliding  when  the  individual  moves  the  ex- 
tremity. 

Treatment. — A  false  neuroma  is  to  be  removed,  if  possi- 
ble, without  destroying  the  nerve-trunk.  If,  in  removing  a 
neuroma,  it  is  necessary  to  exsect  a  portion  of  a  nerve-trunk, 


TCMORS   OR   MORBID    GROWTHS.  22$ 

always  endeavor  to  suture  the  ends  so  as  to  facilitate  resto- 
ration of  function.  For  multiple  neuromata — at  least  should 
the  number  be  large  or  should  molluscum  fibrosum  exist — 
surgery  can  do  nothing.  Plexiform  neuromata  may  often  be 
removed,  but  amputation  may  be  required.  Painful  neuro- 
mata in  stumps  should  be  excised. 

Angfiomata. — These  vascular  or  erectile  tumors  are 
growths  composed  of  blood-vessels. 

Simple  or  capillary  angiomata,  nevi,  or  "  mother's 
marks,"  which  affect  the  skin  or  subcutaneous  tissue,  are 
composed  of  enlarged  and  twisted  capillaries  and  of  anas- 
tomosing vessels  surrounded  by  fat.  These  growths  are 
congenital  or  appear  in  the  first  few  weeks  of  life ;  they  are 
flat  and  slightly  raised,  and  are  of  a  bright-pink  color  if 
composed  chiefly  of  arterioles,  and  are  bluish  if  composed 
mainly  of  venules ;  they  are  but  little  elevated ;  they  can 
be  almost  completely  emptied  by  pressure ;  they  occasion- 
ally pass  away  spontaneously,  but  usually  grow  constantly 
and  may  become  cavernous  ;  they  may  ulcerate  and  occasion 
violent  or  fatal  hemorrhage.  One  or  several  large  vessels 
join  a  nevus  to  adjacent  blood-vessels.  Port-wine  or  claret 
stains  are  pink  or  blue  discolorations  due  to  superficial  nevi 
of  the  skin  ;  they  may  be  small  in  extent  or  they  may 
involve  a  very  large  area,  are  not  elevated,  and  do  not 
usually  spread.  Telangiectasis  is  a  form  of  nevus  involv- 
ing the  skin  and  subcutaneous  tissue  in  which  many  arte- 
rioles and  venules  exist.  Simple  angiomata  are  common 
on  the  forehead,  the  scalp,  the  face,  the  neck,  the  back,  and 
the  extremities.  They  may  appear  on  the  labia,  the  tongue, 
or  the  lips. 

Cavernous  angiomata,  or  venous  nevi,  resemble  in 
structure  the  corpora  cavernosa  of  the  penis ;  there  are 
large  spaces  with  thin  walls  carrying  blood,  and  there  may 
be  distinct  vessels  as  well.  Arteries  send  blood  into  the 
spaces,  and  veins  receive  it  from  the  spaces.  These  chan- 
nels and  sinuses  are  enormously  distended  capillaries.  Cav- 
ernous angiomata  arise  in  the  skin  and  subcutaneous  tis- 
sues ;  they  are  usually  congenital,  but  may  develop  from 
simple  angiomata.  These  cavernous  angiomata  are  purple 
or  blue  in  color,  are  more  distinctly  elevated  than  the  capil- 
lary nevus,  may  be  either  cutaneous  or  subcutaneous,  swell 
when  the  child  cries,  and  are  apt  to  pulsate  ;  they  may  be 
emptied  by  pressure,  and  often  look  like  cysts  with  very  thin 
walls.  Cavernous  angiomata  may  arise  in  the  breast,  the 
tongue,  the  lip,  the  subcutaneous  tissues,  or  the  mu.scles.    If 

15 


226  MODERN  SURGERY. 

an  angioma  contains  an  excess  of  fat,  the  growth  is  called 
a  "  nevoid  lipoma." 

Plexiform  angiomata  are  known  as  "  cirsoid  aneurysms  " 
or  aneurysms  by  anastomosis  (p.  256). 

Treatment. — These  growths  if  large  or  growing  must  be 
treated.  A  capillary  nevus  can  often  be  quickly  cured  by 
touching  it  with  fuming  nitric  acid.  A  second  appHcation 
of  acid  may  be  required.  The  growth  may  be  destroyed  by 
heat — "  a  knitting-needle  at  a  dull-red  heat  or  the  galvano- 
cautery  "  (Wharton).  The  application  of  ethylate  of  sodium 
or  the  employment  of  electrolysis  will  destroy  the  growth. 

Small  port-wine  stains  may  be  removed  by  electrolysis  or 
multiple  incisions,  but  extensive  stains  are  ineffaceable.  Small 
nevi  may  be  ligated  under  harelip  pins  ;  larger  nevi  may  be 
strangulated  in  sections  by  the  Erichsen  suture  or  may  be 
completely  excised.  Excision  is  usually  the  best  plan  for  the 
cure  of  the  cavernous  variety  of  angeiomata.  When  a  large 
cavity  is  left  by  excision  a  plastic  operation  must  be  performed. 
Do  not  use  astringent  injections. 

I/ytnphang"ioinata  are  tumors  composed  of  dilated 
lymph-vessels,  and  are  often,  though  not  invariably,  con- 
genital. The  lymphatic  nevus  is  a  colorless  or  faintly  pink 
elevation  ;  if  it  is  punctured  with  a  needle,  lymph  flows  from 
the  puncture.  One  or  several  nevi  may  be  present  in  the 
same  individual.  The  dilatation  is  due  to  blocking  of  the 
lymph-channels.  Local  lymphangioma  of  the  tongue  is 
manifested  by  a  cluster  of  papillary  projections  containing 
lymph.  Macroglossia  is  a  congenital  enlargement  of  the 
anterior  portion  of  the  tongue,  which  enlargement  grows 
more  and  more  marked  until  finally  the  tongue  is  forced  far 
out  of  the  mouth.  This  condition  of  tongue-enlargement  is 
due  to  lymphangioma  of  the  mucous  membrane.  Lymph 
scrotum  is  due  to  a  similar  growth.  A  collection  of  these 
warty-looking  dilatations  is  called  lymphangiectasis.  Just 
as  there  occur  cavernous  angiomata  among  blood-vessel 
tumors,  there  occur  cavernous  lymphangiomata  among 
lymph-vessel  tumors,  and  the  spaces  are  filled  with  lymph 
instead  of  with  blood.  Areas  affected  with  lymphangiectasis 
are  liable  to  repeated  attacks  of  erysipelas-like  inflammation. 
Whether  this  inflammation  is  causative  or  secondary  is  not 
known.  Certain  it  is  that  in  tropical  countries  blocking  may 
be  brought  about  by  the  filaria  sanguinis  hominis,  a  parasite 
which  lurks  in  the  lymph-vessels  during  the  day  and  is  found 
in  the  blood  only  at  night.  Lymphangiectasis  is  often  the 
first  stage  of  an  elephantiasis  (p.  747). 


TUMORS   OR   MORBID    GROWTHS.  22/ 

Treatment. — Lymphatic  nevus  requires  excision.  In 
macroglos-sia  remove  the  bulk  of  the  mass  by  a  V-shaped 
cut  and  so  stitch  the  mucous  membrane  as  to  close  the 
stump.  In  conditions  due  to  the  filaria,  anilin-blue  has  been 
gi\-en  internally  with  advantage. 

Malig^nant'  Connective-tissue  Tumors,  or  Sarco- 
mata.— The  sarcomata  are  composed  of  embryonic  tissue. 
They  develop  from  connective  tissue,  have  no  definite 
stroma,  and  contain  no  lymphatics.  The  rapidly  growing 
forms  are  very  vascular,  the  blood  flowing  in  vessels  whose 
walls  are  very  thin  or  running  in  canals  whose  boundaries 
are  sarcomatous  cells.  These  tumors  may  pulsate  and  have 
a  bruit,  and  hemorrhages  often  take  place  in  their  substance. 
Slow-growing  sarcomata  have  but  few  vessels.  Sarcoma 
disseminates  by  means  of  the  blood  and  the  vessel-walls, 
particles  of  sarcoma  being  carried  by  the  venous  blood  to 
the  heart  and  from  this  organ  to  the  lungs,  where  they  lodge 
and  form  secondary^  growths.  Emboli  from  these  secondary 
foci  are  sent  out  by  the  arterial  blood  to  various  portions 
of  the  body,  as  the  bones,  kidneys,  brain,  liver,  etc.  This 
process  is  known  as  "  metastasis."  Sarcoma  follows  the 
vein-walls  for  considerable  distances  and  builds  elongated 
masses  inside  the  veins.  Sarcoma  tends  strongly  to  infil- 
trate adjacent  parts.  The  tumor  may  possess  a  capsule  when 
it  is  in  an  early  stage,  but  soon  loses  this  except  in  very 
slow-growing  or  mixed  forms  growing  by  central  proliferation. 
Sarcomata  may  arise  at  any  age  from  birth  to  extreme  senility, 
but  they  are  commonest  during  youth  and  early  middle  age. 
They  are  not  hereditary,  and  often  follow  contusion.  They 
may  be  primar}'  or  may  arise  from  malignant  change  in  an 
innocent  connective-tissue  growth  (chondrosarcoma,  fibro- 
sarcoma, etc.).  A  sarcoma  does  not  tend  to  affect  lymphatic 
glands  except  by  the  accident  of  its  position  ;  and  if  it  does 
implicate  them,  the  sarcomatous  elements  are  carried  rather 
by  the  vein-walls  and  blood  than  by  the  lymph  (melanotic 
sarcoma  implicates  adjacent  glands,  and  so  does  sarcoma  of 
the  tonsil  or  of  the  testicle).  The  skin  over  the  tumor  may  giv^e 
way,  a  bleeding  fungus-mass  protruding  (fungus  haematodes), 
and  suppuration  may  cause  septic  enlargement  of  adjacent 
glands.  After  remov^al  of  a  sarcoma  the  growth  tends  to 
recur,  and  the  recurrent  tumor  may  be  either  more  or  less 
malignant  than  its  predecessor,  the  degree  of  malignancy 
being  in  direct  ratio  to  the  number  and  smallness  of  the  cells. 
A  sarcoma  is  malignant  by  local  tissue-infection  and  by  dis- 
semination.    Sarcomata  rarely  cause  pain  when  they  are  not 


228  MODERN  SURGERY. 

ulcerated.  Sarcomata  are  commonest  in  the  skin  and  con- 
nective tissue  of  the  extremities,  but  they  arise  also  from 
bone,  neuroglia,  periosteum,  in  the  lymphatic  glands,  the 
breast,  the  testicle,  the  eye,  the  parotid,  and  in  other  parts. 
Hemorrhages  into  a  sarcoma  often  occur,  with  the  result 
of  suddenly  increasing  its  size  and  forming  blood-cysts. 
Sarcomata  are  subject  to  partial  fatty  degeneration,  to 
myxomatous  changes  which  produce  cavities  filled  with 
fluid,  to  calcification,  and  occasionally  to  necrosis  of  large 
masses. 

Species  of  Sarcomata. — The  following  species  of  sarco- 
mata are  recognized  : 

1.  Round-cell,  in  which  the  matrix  is  soft  and  vascular. 
The  cells  may  be  small  or  may  be  large.  The  smaller  the 
cell  the  more  malignant  the  growth.  A  small  round-cell 
sarcoma  is  the  most  malignant  variety  of  sarcoma  and  is  soft 
in  consistence. 

2.  Spindle-cell,  which  is  composed  of  bundles  of  spindle- 
cells  lying  in  a  matrix  which  may  be  homogeneous,  but  which- 
may  show  some  attempt  at  fiber-formation.  Rhabdomyoma 
is  a  variety  of  spindle-cell  sarcoma  containing  striated  mus- 
cle-cells. These  spindle-cell  sarcomata  often  contain  carti- 
lage. 

3.  Mixed-cell  sarcoma,  containing  both  of  the  above  varie- 
ties of  cells. 

4.  Giant-cell  or  myeloid,  which  contains  some  round-cells, 
some  spindle-cells,  and  large  cells  with  many  nuclei,  like  the 
cells  of  bone-marrow.  It  is  maroon-colored  on  section.  This 
is  the  least  malignant  form  of  sarcoma,  and  it  sometimes  ad- 
mits of  complete  extirpation  and  cure.  It  tends  to  occur  in 
the  long  bones  as  a  central  sarcoma. 

5.  Alveolar,  in  which  the  cells  are  collected  in  alveoli  as 
are  the  cells  of  cancer.     It  arises  usually  from  a  mole. 

6.  Melanotic,  which  may  be  composed  of  either  round- 
cells  or  spindle-cells  containing  a  black  pigment. 

7.  Lymphosarcoma,  which  is  composed  of  small  round- 
cells  held  in  a  delicate  network,  the  tissue  somewhat  resem- 
bling that  of  a  lymphatic  gland. 

Clinical  Varieties  of  Sarcoma. — The  following  are  the 
clinical  varieties  of  sarcoma : 

Melanotic  or  black  sarcoma,  the  color  of  which  is  due  to 
pigment  in  the  cells  or  matrix.  These  growths  are  usually 
composed  of  round-cells,  but  may  consist  of  spindle-cells ; 
they  are  sometimes  alveolar,  and  spring  from  parts  which 
contain  pigment  (skin  and  choroid  coat  of  the  eye)  ;  they  are 


TUMORS   OR   MORBID    GROWTHS.  229 

apt  to  arise  from  pigmented  moles  ;  they  are  very  malig- 
nant ;  they  implicate  related  lymphatic  glands,  and  during 
their  existence  the  urine  contains  pigment. 

GliosarcoDia  is  a  sarcoma  of  neuroglia.  A  pure  glioma  is 
composed  of  adult  connective  tissue  ;  but,  as  a  matter  of  fact, 
pure  glioma  almost  never  arises,  and  the  growth  practically 
always  contains  numerous  small  round-cells  and  is  properly 
a  sarcoma.  It  springs  from  the  neuroglia  of  the  central  ner- 
vous system,  and  is  usually  of  about  the  consistence  of  the 
cortex  of  the  brain;  it  is  generally  single,  and  does  not 
cause  secondary  growths.  A  gliomatosis  of  the  cord  produces 
that  remarkable  disease  known  as  "  syringomyelia."  The 
symptoms  of  glioma  of  the  brain  depend  upon  its  situation. 

Hcnioryhagic  sarcoma  is  a  sarcoma  containing  blood- 
cysts,  the  results  of  parenchymatous  hemorrhages. 

Cyliudroma,  or  Plcxiforin  Sarcoma. — In  this  variety  the 
cells  adjacent  to  vessels  have  undergone  hyaline  degenera- 
tion ;  the  cells  distant  from  vessels  are  unchanged.  Section 
shows  the  normal  cells  apparently  contained  in  spaces  with 
h}-aline  walls. 

Mixed  tumors  consist  partly  of  mature  and  partly  of 
embryonic  tissue,  the  cellular  elements  exceeding  the  adult 
elements  in  amount.  Among  these  mixed  tumors  are  fibro- 
sarcoma or  the  recurrent  fibroid  tumor,  myxosarcoma, 
chondrosarcoma,  and  osteosarcoma. 

Treatment  of  Sarcomata. — Remove  a  sarcoma  at  once  if 
it  is  in  an  accessible  spot.  Never  delay  removal.  Cut  well 
clear  of  it.  The  rapidly  growing  soft  sarcomata  will  almost 
inevitably  return,  and  the  very  malignant  variety,  if  uninter- 
fered  with,  may  terminate  life  in  six  months ;  but  operation 
postpones  the  evil  day  and  renders  it  possible  that  death  will 
occur  from  metastasis  in  an  organ,  and  that  the  patient  will 
escape  the  horrors  of  ulceration  and  hemorrhage  from  the 
original  tumor.  Slowly  growing  and  hard  tumors  offer 
some  prospects  of  cure.  The  mixed  tumor  (as  a  recurrent 
fibroid)  may  repeatedly  recur,  and  yet  the  patient  may  be 
cured  at  last  by  a  sixth,  an  eighth,  or  a  tenth  operation. 
In  sarcoma  of  a  long  bone  amputation  should,  as  a  rule, 
be  performed,  though  in  some  cases  of  giant-cell  sarcoma 
excision  may  be  employed.  In  sarcoma  of  the  jaw-bone, 
excision  ;  of  the  eye,  enucleation-;  and  of  the  testicle,  castra- 
tion, is  demanded.  Sarcoma  of  the  ovary  in  adults  demands 
removal,  but  in  children  the  operation  is  useless.  Sarcoma 
of  the  kidney  in  adults  calls  for  nephrectomy,  but  in  chil- 
dren the  operation  is  of  little  avail.     In  melanotic  sarcoma 


230  MODERN  SURGERY. 

remove  the  growth  and  adjacent  lymph-glands,  or  in  some 
cases  amputate.  Removal  of  a  sarcoma  when  there  is  no 
hope  of  a  cure  is  often  justifiable  to  prolong  life,  to  relieve 
the  patient  of  a  foul,  offensive,  bleeding  mass,  and  to  permit 
of  an  easier  road  to  death  by  means  of  metastasis  to  an 
internal  organ.  Wright  advocates  internal  treatment  for  sar- 
coma' and  for  cancer.  He  advises  that  bromid  of  arsenic 
be  given  for  a  long  period  of  time,  the  dose  being  gr.  -^  to 
gr.  yV  ^^"I^^^  ^^^^  meal.  Before  meals  gr.  x  of  carbonate  of 
lime  are  advised.  This  treatment,  Wright  holds,  should  be 
used  before,  and  for  many  months  after,  operation,  as  an  aid 
to  surgery.     In  inoperable  cases  it  may  be  tried.^ 

It  has  been  observed  that  an  attack  of  erysipelas  occasion- 
ally greatly  benefits  a  sarcoma,  causing  large  masses  of  the 
growth  to  soften  or  to  slough  and  expose  a  granulating  sur- 
fece.  Busch  noticed  this  in  1866.  It  has  been  suggested 
that  in  inoperable  cases  of  sarcoma  these  conditions  might  be 
established  artificially.  Fehleisen  inoculated  tumors  with 
cultures  of  erysipelas.  Lassar  in  1891  employed  the  toxins 
(cultures  rendered  sterile  by  heat  and  filtration).  In  1892 
Coley  began  his  observations.  The  first  plan  was  as  follows  : 
a  bouillon-culture  is  made  of  the  streptococci ;  this  culture  is 
filtered  through  porcelain  and  an  injection  is  given  once  a  day 
into  and  about  the  sarcoma.  The  first  dose  is  TTlx,  and  it  is 
increased ;  it  should  cause  a  febrile  reaction,  and  sometimes 
establishes  softening  or  suppuration.  Coley's  present  method 
is  as  follows :  make  cultures  of  erysipelas  cocci  in  cacao-broth  ; 
after  three  weeks  inoculate  them  with  the  bacillus  prodigiosus, 
and  cultivate  the  mixed  growth  for  four  weeks.  They  are 
maintained  at  58°  C.  until  they  become  sterile.  This  sterile 
fluid  contains  the  toxins.  The  dose  is  from  i  to  8  minims.  The 
material  is  very  powerful  and  may  cause  high  fever.  Begin 
with  a  small  dose  and  gradually  increase  until  the  proper 
amount  of  reaction  ensues  (103°- 104°  F.).  The  injection 
may  be  about  the  sarcoma  or  at  a  distant  point.  The  exact 
status  of  this  plan  is  not  determined ;  it  has  improved  and 
even  cured  some  cases,  but  is  not  free  from  danger.  Coley 
believes  that  the  value  of  the  agent  is  proved,  but  Senn, 
Keen,  Kocher,  and  others  are  very  doubtful  of  its  value. 
Emmerich  and  Scholl  claim  good  results  from  the  injection 
of  erysipelas  serum.  A  sh'eep  is  injected  with  cultures  of 
erysipelas,  the  blood  is  drawn,  the  serum  separated,  filtered 
to  remove  cocci,  and  injected  about  the  sarcoma.  Results 
are  not  definite.    Among  other  agents  which  have  been  used 

1  Annals  of  Surgery,  April,  1893. 


TUMORS   OK   MORBID    GROWTHS.  23 1 

to  inject  inoperable  sarcoma  we  may  mention  alcohol,  chlo- 
rid  of  zinc,  arsenic,  corrosive  sublimate,  thiosinamin,  pepsin, 
alkalies,  etc.  The  injection  of  anilin-products  into  the  sar- 
coma, which  has  received  a  qualified  commendation  from 
some  observers,  has  been  abandoned  by  most  surgeons  after 
careful  trial. 

Innocent  Bpithelial  Tumors. — These  growths  imi- 
tate an  epithelial  tissue  of  the  mature  and  healthy  organ- 
ism. 

Papillomata,  or  Warts. — These  growths  are  formed 
upon  the  type  of  cutaneous  and  mucous  papillae.  A  papil- 
loma consists  of  a  fibrous  stroma  which  contains  blood- 
vessels and  lymphatics  and  is  covered  by  epithelium  of 
the  variety  appertaining  to  the  diseased  part.  Warts  grow 
from  the  skin  and  from  mucous  membranes ;  they  may 
be  single  or  multiple ;  they  may  be  painless  or  may  be 
ulcerated  and  bleeding ;  great  masses  may  gather  around 
the  anus,  the  vagina,  or  the  penis  during  the  existence  of  a 
filthy  discharge,  and  crops  appear  on  the  hands  of  those 
who  work  in  irritant  material  (as  petroleum).  A  large 
crop  of  warts  may  disappear  in  a  single  night ;  hence  the 
popular  belief  in  the  efficacy  of  charms.  A  single  wart 
may  reach  a  large  size  and  become  pigmented.  The  squa- 
mous epithelium  covering  a  skin-wart  may  become  horny 
(a  wart-horn).  Other  cutaneous  horns  arise  from  the  nails, 
from  the  scars  of  burns,  or  from  ruptured  sebaceous  cysts. 

Villous  papillomata  grow  chiefly  from  the  bladder ;  they 
form  tufts  like  the  villous  processes  of  the  chorion  ;  they 
may  be  single  or  multiple,  and  may  be  sessile  or  peduncu- 
lated ;  they  are  very  vascular,  and  are  apt  to  bleed  freely. 
Papillomata  may  arise  in  cysts  of  the  paroophoron,  in  cysts 
of  the  mammary  gland,  from  the  choroid  plexuses  of  the 
ventricles  of  the  brain,  and  from  the  spinal  membranes  Any 
papilloma  may  become  a  cancer. 

Treatment. — Venereal  warts  are  treated  by  repeatedly 
washing  with  peroxid  of  hydrogen,  drying  with  cotton,  and 
dusting  with  a  powder  composed  of  equal  parts  of  calomel 
and  subnitrate  of  bismuth,  or  oxid  of  zinc  and  iodoform,  or 
borated  talcum.  If  they  do  not  soon  dry  up,  cut  them  off 
with  scissors  and  burn  with  the  Paquelin  cautery.  Ordi- 
nary warts  may  usually  be  destroyed  in  a  short  time  by 
daily  applications  of  lactic  or  chromic  acid.  In  multiple 
warts  of  the  face  Kaposi  applies  daily  for  several  days  a  por- 
tion of  the  following  combination  :  sublimed  sulphur,  .^5  ;  gly- 
cerin, 31^;    acetic    acid,  .32|-.     Keeping    a    wart    constantly 


232  MODERN  SURGERY. 

moist  with  castor  oil  will  often  cause  it  to  drop  off.  Warts, 
and  even  extensive  callosities,  may  be  removed  by  painting 
once  a  day  for  five  days  with  pure  carbohc  acid  and  cover- 
ing with  lint  kept  wet  with  boric  acid.  A  convenient  plan 
is  to  paint  a  wart  daily  with  a  solution  containing  i  part  of 
corrosive  sublimate  to  30  parts  of  collodion  (hydrarg.  chlor. 
corros.,  z\\  collodion,  315).  Large  warts  should  be  freely 
excised.  Villous  papillomata  of  the  bladder  demand  the 
performance  of  a  suprapubic  cystotomy  in  order  to  remove 
them. 

Adenomata. — These  glandular  tumors  are  composed 
of  tissue  identical  with  that  of  normal  glands,  and  they  may 
contain  acini  and  ducts  like  racemose  glands  or  tubes  like 
tubular  glands.  They  grow  from  secreting  glands,  but  can- 
not produce  the  secretion  of  the  glands  from  which  they 
spring,  or,  if  they  do  secrete,  the  fluid  is  retained,  and  not 
discharged  by  the  gland-duct.  Adenomata  occur  in  the 
mammary  gland,  the  parotid,  the  ovary,  the  thyroid  gland, 
the  liver,  the  sweat-glands,  and  the  prostate,  and  as  pedun- 
culated growths  from  the  mucous  lining  of  the  intestine  and 
uterus.  They  are  encapsuled,  are  usually  single,  but  may  be 
multiple,  are  of  slow  growth,  but  may  attain  a  great  size  ; 
they  do  not  tend  to  recur  after  thorough  removal,  do  not 
involve  adjacent  glands,  and  do  not  disseminate ;  they  are 
firm  to  the  touch  ;  they  tend  to  become  cystic  (especially  in 
the  thyroid),  the  fluid  which  distends  the  ducts  being  due  to 
mucoid  liquefaction  of  the  proliferating  epithelium. 

In  the  breast  a  fibro-adenoma  has  a  distinct  capsule ;  it  is 
elastic  and  movable,  is  usually  superficial,  and  one  occasion- 
ally exists  in  each  gland.  They  are  most  common  before 
the  age  of  thirty,  and  are  often  painful,  especially  during  men- 
struation. Cystic  adenomata  of  the  breast  attain  a  large  size  ; 
they  are  encapsuled  and  grow  slowly,  are  most  common 
after  the  thirtieth  year,  and  are  rarely  painful.  Both  fibro- 
adenoma and  cystic  adenoma  may  arise  in  the  male  breast. 
Young  unmarried  women  not  unusually  develop  in  the 
breast  small,  very  tender,  and  painful  bodies,  most  usually 
around  the  edge  of  the  areola,  which  bodies  increase  in  size 
and  become  more  tender  during  menstruation  ;  they  are  only 
cysts  of  the  mammary  tissue. 

Adenomata  of  the  thyroid  gland  begin  before  the  fifteenth 
year  (Gross).  Adenomata  may  arise  in  the  prostate  if  that 
gland  be  already  the  seat  of  senile  hypertrophy.  Adenomata 
of  mucous  glands  may  arise  in  the  young  or  the  middle- 
aged. 


rC'MORS   OR  MORBID    GROWTHS.  233 

Treatment. — Adenomata  require  extirpation.  By  confus- 
ing adenomata  of  the  mammary  gland  with  .small  cyst.s  of 
that  structure  an  erroneous  belief  has  arisen  that  the  former, 
as  well  as  the  latter,  may  sometimes  be  cured  by  the  local 
use  of  iodin,  mercury,  and  ichthyol  and  the  internal  use  of 
iodid  of  potassium.     The  treatment  is  excision. 

Malignant  Epithelial  Tumors,  Carcinomata,  or 
Cancers. — Cancers  are  tumors  growing  from  epithelial 
surfaces,  and  are  composed  of  epithelial  cells  which  are 
clustered  in  spaces,  nests,  or  alveoli  of  fibrous  tissue.  The 
cells  of  a  cluster  are  not  separated  by  any  stroma,  and  the 
walls  of  the  alveoli  carry  blood-vessels  and  lymphatics. 
The  growth  may  be  cancerous  from  the  start,  or  may  have 
begun  as  an  innocent  epithelial  tumor.  Cancers  are  always 
derived  from  epithelium  (of  glands,  of  skin,  of  mucous  mem- 
brane, etc.),  and  if  found  in  a  non-epithelial  tissue  must  be 
secondary.  They  have  no  capsules,  rapidly  infiltrate  sur- 
rounding tissues,  and  are  firmly  anchored  and  immovable. 
In  the  beginning  a  cancer  is  a  local  lesion,  but  it  soon  attacks 
related  lymph-glands  and  by  means  of  the  lymph,  and  very 
rarely  by  the  blood  (Thiersch  and  Waldeyer),  is  dissemi- 
nated throughout  the  system,  secondary  growths  arising 
which  are  identical  with  the  parent  growth.  Cancer  is  rare 
before  the  age  of  forty,  and  never  occurs  before  puberty ; 
seems  occasionally  to  be  hereditary ;  and  is  sometimes 
linked  with  continued  irritation  as  a  cause  (cancer  of  the 
penis  in  phimosis  ;  cancer  of  the  lip  from  the  hot  stem  of  a 
clay  pipe ;  chimney-sweeps'  cancer  from  soot  in  the  scrotal 
folds ;  cancer  of  the  gall-bladder  when  gall-stones  exist). 
The  weight  of  opinion  is  opposed  to  the  theory  that  cancer 
is  of  parasitic  origin.  Tillmanns  says  that  the  presence  of 
protozoa  has  never  been  proved.^  The  same  author  says 
that  transplantation  has  taken  place,  but  only  by  auto-infec- 
tion or  by  transplantation  to  an  animal  of  the  same  species. 
The  facts  that  transplantation  can  be  sometimes  carried  out, 
and  that  contagion  is  a  possible  occurrence  under  excep- 
tional circumstances,  do  not  prove  that  cancer  is  a  para- 
sitic disease,  but  simply  prov^e  that  it  can  be  transplanted. 
It  is  not  that  the  cancer  carries  a  parasite  which  will  cause 
the  disease  in  sound  tissues,  but  rather  that  the  cells  of  the 
cancer  may  themselves  take  root  and  grow  in  sound  tissues 
(p.  211).  Dennis  says  that  all  clinical  evidence  points 
strongly  to  the  view  that  inflammatory  changes   following 

1   Verhandlungen  der  deutschen  Gesellschaft  fiir  Chirtirgie,  XXIV.  Kongress, 
1895- 


234  MODERN  SURGERY. 

irritation  are  responsible  for  cancer.  Cancer  is  often  the 
seat  of  pricking  pain  ;  tends  strongly  to  recur  after  removal ; 
is  prone  to  ulcerate,  causing  pain,  hemorrhage,  and  cachexia ; 
makes  rapid  progress,  and  is  often  fatal  in  from  one  to  two 
and  a  half  years.  It  is  more  common  in  women  than  in 
men,  and  rarely  exists  with  tubercle.  After  a  cancer  has 
existed  for  a  time  in  an  important  structure,  or  after  a  super- 
ficial cancer  has  ulcerated  and  become  hemorrhagic,  there  are 
noted  in  the  individual  evidences  of  illness  and  exhaustion. 
We  speak  of  this  condition  as  the  "  cancerous  cachexia," 
and  in  it  the  muscles  are  wasted,  the  body-weight  is  con- 
stantly diminishing,  the  complexion  is  sallow,  the  face  is 
sunken,  pearly  white  conjunctivae  contrast  strongly  with  the 
yellow  skin,  the  pulse  is  weak  and  rapid,  and  night-sweats 
add  to  the  exhaustion.  The  above  condition  is  due  to  the 
absorption  of  toxic  products  from  the  diseased  tissues,  and 
also  to  pain,  loss  of  sleep,  bleeding,  deprivation  of  exercise, 
malassimilation  of  food,  and  anxiety.  Cancer  may  kill  by 
obstructing  a  canal,  by  destroying  the  functions  of  a  viscus 
or  organ,  by  hemorrhage,  by  anemia,  by  sepsis,  or  by 
exhaustion. 

Classification  of  Carcinomata. — Carcinomata  are  classi- 
fied as  follows  :  i.  Squamous-celled  cancer,  or  epithelioma; 
2.  Rodent  ulcer,  or  Jacob's  ulcer ;  3.  Spheroidal-celled  cancer 
{a,  scirrhus  ;  b,  encephaloid ;  c,  colloid) ;  and  4.  Cylindrical- 
celled  cancer. 

Epitheliomata. — An  epithelioma  may  arise  wherever  there 
is  pavement-epithelium,  and  it  is  especially  apt  to  appear  at 
the  junctions  of  skin  and  mucous  membrane  (as  the  lips)  or 
the  point  of  juxtaposition  of  different  kinds  of  epithelium. 
These  growths  arise  in  the  anus,  vagina,  penis,  scrotum,  lips, 
tongue,  mouth,  nose,  and  other  situations.  In  epithelioma 
there  is  an  ingrowth  of  surface-epithelium  into  the  sub-epi- 
thelial connective  tissue,  colonies  of  cells  growing  inward  and 
forming  epithelial  nests.  It  may  arise  without  discoverable 
cause,  it  may  follow  prolonged  irritation,  or  it  may  arise  in  a 
wart  or  fissure.  In  the  nipple  it  is  often,  and  in  the  scrotum 
and  nose  it  is  occasionally,  preceded  by  a  persistent  eczema, 
due  probably  to  psorosperms  and  known  as  Pagefs  disease. 
Paget's  disease  is  not  a  true  eczema,  but  is  rather  a  malig- 
nant dermatitis.  A  crust  gathers  on  the  part,  and  beneath  this 
crust  is  a  raw,  red,  and  moist  surface,  the  edge  of  which  is 
slightly  elevated  and  somewhat  indurated.  In  the  begin- 
ning there  is  a  strong  resemblance  to  eczema.  The  nipple 
is  apt  to  retract.     The  parts  are  the  seat  of  a  constant  itch- 


TUMORS   OR   MORBID    GROWTHS.  235 

ing  and  scalding  sensation.  The  area  may  become  cancerous 
in  a  few  weeks,  but  may  not  for  years.  Epithelioma  generally 
begins  as  a  warty  protuberance  which  soon  ulcerates.  The 
malignant  ulcer  has  a  hard,  irregular  base,  uneven  edges,  a 
foul,  fungus-like  bottom,  and  gives  off  a  sanious  or  ichorous 
discharge.  This  ulcer  is  the  seat  of  sharp,  pricking  pain, 
sometimes  bleeds,  and  extends  over  a  considerable  area,  em- 
bracing and  destroying  all  structures.  Epithelioma  affects 
lymphatic  glands  usually  early,  but  its  action  may  be  delayed 
for  eight  or  ten  months.  These  glands  break  down  in  ulcer- 
ation, making  frightful  gaps  and  often  causing  fatal  hemor- 
rhage. Dissemination  is  not  nearly  so  common  as  in  other 
forms  of  cancer,  but  it  does  sometimes  occur. 

A  rodent  or  Jacob's  ulcer  is  scarcely  ever  met  with  except 
upon  the  face,  though  Jonathan  Hutchinson  saw  one  upon 
the  forearm,  and  James  Berry  one  upon  the  arm.  It  is 
especially  common  upon  the  nose  and  forehead.  It  begins 
after  the  age  of  forty  as  a  little  warty  prominence  which 
ulcerates  in  the  center,  the  ulceration  progressing  at  a  rate 
equal  to  the  new  growth.  It  becomes  deep  ;  is  not  crusted  ; 
its  edges  are  hard  and  everted ;  and  the  parts  about  contain 
numbers  of  visible  vessels.  Jacob's  ulcer  grows  slowly,  may 
last  for  years,  does  not  involve  the  lymphatics,  produces  no 
constitutional  cachexia,  and  is  rarely  fatal.  It  is  an  ulcer 
with  irregular  edges  and  a  smooth  base  of  a  grayish  color, 
its  discharge  being  thin  and  acrid,  and  is  considered  to  be  a 
malignant  epithelial  growth  which  springs  from  a  sweat-gland, 
a  sebaceous  gland,  or  a  hair-follicle,  but  Kanthack  asserts 
that  before  ulceration  the  rete  and  the  sweat-glands  are  nor- 
mal, but  the  sebaceous  glands  are  destroyed.  The  base  and 
edges  of  the  ulcer  are  hard,  which  differentiates  it  from  lupus, 
and  from  lupus  the  bacilli  of  tubercle  may  sometimes  be 
cultivated  (p.  152).  Rodent  ulcer  begins  below  the  skin, 
ordinary  epithelioma  begins  in  the  skin  (Butlin),  and  a  rodent 
ulcer  contains  no  cell-nests. 

Spheroidal-celled  Carcinoviata. — {a)  Scirrhous  carcinoma  is 
a  white  and  fibrous  mass  which  has  no  capsule,  which  infil- 
trates tissues,  and  which  draws  in  toward  it,  by  the  contrac- 
tion of  its  outlying  processes,  adjacent  soft  parts,  thus  pro- 
ducing dimpling,  or,  as  in  the  breast,  retraction  of  the  nipple. 
It  is  composed  of  spheroidal  cells  in  alveoli  formed  of  con- 
nective-tissue bands.  The  commonest  seat  of  scirrhus  is  the 
female  breast.  It  occurs  also  in  the  skin,  vagina,  rectum, 
prostate,  uterus,  stomach,  and  esophagus.  It  is  most  fre- 
quent in  women  after  forty.     It  begins  as  a  hard  lump  which 


236  AIODERN  SURGERY. 

is  at  first  painless,  but  soon  becomes  the  seat  of  an  acute, 
localized,  pricking  pain.  This  lump  grows  and  becomes  ir- 
regular and  adherent,  causing  puckering  of  the  soft  parts. 
After  the  skin  or  mucous  membrane  above  it  has  become 
infiltrated  ulceration  takes  place  and  a  fungous  mass  pro- 
trudes which  bleeds  and  suppurates.  The  adjacent  lymphatics 
soon  become  involved,  and  the  constitutional  involvement  is 
rapid  and  certain. 

{b)  EncepJialoid  carcinoma  is  a  soft  gray  or  brain-like  mass. 
It  is  a  rare  growth,  it  has  no  capsule,  and  it  may  appear  in  the 
kidney,  liver,  ovary,  testicle,  mammary  gland,  stomach,  blad- 
der, and  maxillary  antrum.  An  encephaloid  cancer  often 
contains  cavities  filled  with  blood,  and  this  variety  is  known 
as  a  "  hematoid  "  or  a  "  telangiectatic  "  carcinoma.  These 
growths  are  soft  and  semi-fluctuating,  they  infiltrate  rapidly 
and  soon  fungate,  and  they  terminate  life  in  from  a  year  to  a 
year  and  a  half  If  the  cells  of  encephaloid  become  filled 
with  melanin,  we  have  the  condition  known  as  "  melanosis  " 
or  "  melanotic  cancer." 

[c)  Colloid  carcino7na  arises  from  either  a  scirrhus  or  an  en- 
cephaloid cancer  when  the  cells  or  stroma  undergo  colloid 
degeneration.  On  section  we  see  in  the  center  of  the  growth 
a  series  of  cavities  filled  with  a  material  resembling  honey  or 
jelly;  the  periphery  often  shows  an  ordinary  scirrhus  or 
encephaloid  cancer.  Colloid  degeneration  is  most  prone  to 
attack  cancers  of  the  stomach,  mammary  gland,  and  intes- 
tine. 

Cylindrical-celled  carcinoniata  which  occur  in  the  rectum 
are  known  as  "adenoid"  or  "glandular"  cancers.  They 
may  occur  in  this  region  at  a  much  earlier  age  than  do  can- 
cers elsewhere,  being  not  uncommon  between  the  ages  of 
twenty-eight  and  forty.  At  first  covered  by  mucous  mem- 
brane, they  soon  ulcerate  and  involve  the  submucous  and 
muscular  coats  in  the  growth.  They  grow  rather  slowly, 
and  take  usually  from  four  to  six  years  to  kill.  They  usu- 
ally, but  not  always,  cause  lymphatic  involvement  and  con- 
stitutional infection.  They  are  composed  of  a  stroma  of 
fibers  between  which  lie  tubular  glands  lined  with  columnar 
epithelium  and  masses  of  epithelial  cells. 

Treatment. — Carcinomata  demand  early  and  free  excision, 
with  removal  of  implicated  glands.  A  certain  proportion 
can  be  cured.  Recurrent  growths  may  be  removed  as  a 
palliative  measure,  to  lessen  pain  and  to  relieve  the  patient 
from  ulceration  and  hemorrhage.  If  a  growth  does  not  recur 
within  five  years  after  removal,  a  cure  has  probably  been  at- 


TC'J/OA'S   OH   MORBID    GROWTHS.  237 

tained.  A  rodent  ulcer  should  be  excised  or  else  be  curetted 
and  cauterized  with  the  hot  iron  or  the  Paquelin  cautery.  In 
cancer  of  the  lower  lip,  remove  the  growth  by  a  V-shaped 
incision  or  cut  away  the  entire  lip  and  remove  the  glands 
beneath  the  jaw ;  in  cancer  of  the  tongue,  excise  this  organ 
and  any  enlarged  glands  ;  in  cancer  of  the  breast,  remove  the 
breast  and  pectoral  fascia  and  take  away  the  fat  and  glands 
of  the  axilla ;  in  cancer  of  the  rectum,  if  near  the  surface, 
excise  the  rectum  from  below ;  if  above  five  inches  from  the 
anus,  do  the  sacral  resection  of  Kraske  and  then  remove  the 
growth  ;  in  cancer  of  the  esophagus,  perform  gastrostomy ;  in 
cancer  of  the  pylorus,  perform  pylorectomy  or  gastro-enter- 
ostomy ;  in  cancer  of  the  boivel,  do  resection  with  end-to-end 
approximation,  side-track  the  diseased  area  by  an  anasto- 
mosis, or  make  an  artificial  anus  ;  in  cancer  of  the  penis, 
amputate  and  remove  the  glands  of  the  groin.  Erysipelas 
toxins  and  erysipelas  serum  have  been  tried  in  inoperable 
carcinoma,  but  without  any  positive  benefit.  The  same  is 
true  of  pyoktanin,  thiosinamin,  and  of  all  other  drugs  that 
have  been  suggested. 

Cysts. — A  cyst  is  a  sac  containing  a  fluid  or  a  semi-fluid. 

Division  of  Cysts. — Cysts  are  divided  into  (i)  Retention- 
cysts,  which  are  due  to  blocking  up  of  the  excretory  ducts 
of  glands  and  accumulation  of  the  glandular  secretions.  These 
comprise  sebaceous  cysts  or  wens,  serous  cysts,  mucous 
cysts,  salivary  cysts,  milk-cysts,  oil-cysts,  and  seminal  cysts. 
(2)  Exudation-cysts,  which  are  due  to  accumulations  in  closed 
cavities.  These  comprise  synovial  cysts  (ganglions  and 
bursse).  Dentigerous  cysts  used  to  be  considered  under 
this  head.  (3)  Dermoid  cysts,  which  are  congenital  and 
arise  from  inversion  of  the  cutis  and  imperfectly  closed 
fetal  clefts.  (4)  Cystomas,  which  are  cysts  of  new  forma- 
tion due  to  cystic  degeneration  of  connective  tissue.  These 
cysts  are  found  in  the  neck  (hygroma),  in  the  arm-pit,  and 
in  the  perineum.  An  example  of  a  cystoma  is  found  in 
the  bursa  which  develops  from  pressure.  (5)  Extravasation- 
cysts,  that  form  around  blood-extravasations.  (6)  Hydatid 
cysts,  or  cysts  due  to  the  echinococcus  or  tape-worm  of 
the  dog.  A  mother-cyst  is  formed,  which  becomes  filled 
with  daughter-cysts  floating  in  a  saline  liquor  containing 
hooklets. 

Sebaceous  cysts  arise  when  the  excretory  duct  of  a  seba- 
ceous gland  is  blocked  by  dirt  or  occluded  by  inflammation. 
The  orifice  of  the  duct  is  often  visible  as  a  black  speck  over 
the  center  of  the  cyst.     They  are  very  common  in  the  scalp, 


238  MODERN  SURGERY. 

being  known  as  "  wens,"  and  upon  the  face,  neck,  shoulders, 
and  back.  Arising  in  the  skin,  and  not  under  it,  the  skin 
cannot  be  freely  moved  over  a  sebaceous  cyst.  A  sebaceous 
cyst  is  lined  with  epithelium  and  is  filled  with  foul-smelling 
sebaceous  material.  A  sebaceous  cyst  may  suppurate.  When 
a  cyst  ruptures  and  the  contents  become  hard,  a  horn  is 
formed.  The  other  form  of  horn  has  been  previously  alluded 
to  as  due  to  horny  transformation  of  a  wart. 

Treatment. — To  treat  a  sebaceous  cyst,  dissect  it  entirely 
away  with  scissors  or  an  Allis  dissector,  trying  not  to  rupture 
the  sac.  If  even  a  small  particle  of  it  is  left,  the  cyst  will 
return.  If  it  ruptures  during  removal  and  it  is  feared  that 
some  portion  may  remain,  swab  out  the  wound  with  pure 
carbolic  acid.  If  acid  is  not  used,  close  without  drainage; 
but  if  acid  is  used,  drain  for  twenty-four  hours.  If  an 
abscess  forms  in  a  sebaceous  cyst,  open  it,  grasp  the  edges 
of  the  cyst-lining  with  forceps,  dissect  out  this  lining  with 
scissors  curved  on  the  flat,  cauterize  with  pure  carbolic  acid, 
and  drain  for  twenty-four  hours. 

Dermoid  cysts,  are  lined  with  true  skin.  They  contain 
sebaceous  matter,  hair,  teeth,  or  other  epiblastic  products. 
They  are  always  congenital,  but  may  be  so  small  at  birth  as 
to  escape  notice  for  years.  They  may  be  distinguished  from 
sebaceous  cysts  by  the  fact  that  they  always  lie  below  the 
deep  fascia,  and  hence  the  skin  is  freely  movable  over  them. 
They  are  met  with  at  the  root  of  the  nose,  at  the  orbital 
angles,  in  the  eyelids,  upon  the  floor  of  the  mouth,  over  the 
sacrum  or  coccyx,  and  in  the  ovaries,  the  testicles,  the  brain, 
the  eyes,  the  mediastinum,  the  lungs,  the  omentum,  the 
mesentery,  and  the  carotid  sheaths.  They  are  due  to  imper- 
fect closure  of  fetal  clefts  and  inclusion  of  epiblast.  If  a 
dermoid  cyst  contains  bones,  it  shows  that  mesoblast  was 
included  as  well  as  epiblast. 

Treatment. — To  treat  a  dermoid  cyst,  excise,  if  accessible, 
the  same  as  in  the  case  of  a  sebaceous  cyst.  If  it  lies  over 
bone,  go  down  to  the  bone  :  the  growth  will  be  found  ad- 
herent, so  remove  a  portion  of  periosteum  with  the  cyst. 

Hydatid  cysts  are  especially  common  in  Iceland,  and  are 
frequent  in  Australia,  but  are  very  rare  in  the  United  States. 
They  are  due  to  the  echinococcus.  The  adult  echinococcus 
is  the  tapeworm  of  the  dog  (taenia  echinococcus),  and  its 
ova  or  larvae  gain  access  to  man's  body  by  accompanying  the 
food  he  eats  and  passing  into  the  alimentary  canal,  from 
which  canal  they  are  transported  to  various  organs 
by  the    blood.     Osier    says    the    embryo    (which    has    six 


DISEASES  AND   IXJURIES   OF  HEART  AND    VESSELS.     239 

booklets)  burrows  through  the  wall  of  the  bowel  and  en- 
ters the  peritoneal  cavity  or  muscles  ;  it  may  enter  the  portal 
vessels  and  reach  the  liver,  or  may  enter  the  systemic  cir- 
culation and  pass  to  distant  parts.  The  danger  depends  on 
two  factors  :  "  the  situation  and  the  liability  of  the  cyst  to 
suppurate  "  (Sidney  Coupland).  The  organs  most  usually 
attacked  are  the  liver  and  lung.  In  60  per  cent,  of  cases  the 
liver  suffers,  and  in  12  per  cent,  the  lung  (Thomas).  Cysts 
sometimes  arise  in  the  intestine,  genito-urinary  passages,  brain, 
or  spinal  canal.  When  the  embryo  lodges  the  booklets  dis- 
appear and  the  embryo  is  converted  into  a  cyst.  This  cyst 
is  composed  of  two  layers,  an  outer  capsule  (cuticular  mem- 
brane) and  an  inner  layer  (endocyst).  The  cyst  contains  clear 
fluid  (Osier).  As  the  cyst  grows,  daughter-cysts  bud  out 
from  the  wall  of  the  mother-cysts,  the  structure  of  the  daugh- 
ter-cysts being  identical  with  that  of  the  mother-cyst.  From 
the  lining  membrane  of  all  the  cysts,  after  a  time,  growths 
arise  known  as  scolices,  which  represent  the  head  of  the 
echinococcus  and  exhibit  four  sucking  disks  and  a  row  of 
booklets  (Osier). 

The  fluid  is  not  albuminous,  is  occasionally  saccharine,  is 
thin  and  clear,  and  may  contain  scolices  or  booklets. 

A  hydatid  cyst  may  calcify,  may  rupture,  or  may  suppurate. 
These  cysts  are  very  firm,  but  usually  fluctuate.  Palpation 
with  one  hand  while  percussion  is  practised  with  the  other 
gives  a  persistent  tremor  (hydatid  fremitus).  The  fluid  should 
be  drawn  and  examined.  When  a  cyst  suppurates  positive 
constitutional  and  local  symptoms  arise. 

Treatment. — In  a  hydatid  cyst  of  a  superficial  part  incise 
and  dissect  out  the  sac-wall  (Gardner).  Unruptured  hydatid 
cysts  of  superficial  structures  should  be  dissected  out. 
Abdominal  cysts  should  be  radically  removed  if  possible ; 
if  this  is  not  possible,  stitch  to  the  peritoneum,  incise,  irri- 
gate, and  drain  with  gauze.  Bond  advocated  evacuating  the 
cyst,  closing  it  with  sutures  and  dropping  it  back  in  the 
abdomen.  Gardner  says  tapping  is  dangerous,  as  it  may 
cause  rupture  of  the  cyst.  If  aspiration  is  performed  to 
settle  a  diagnosis,  operate  at  once  after  doing  it. 

XVIII.    DISEASES    AND    INJURIES    OF    THE     HEART 
AND  VESSELS. 

Heart  and  Pericardium. — In  an  acute  pulmonary  con- 
gestion the  venous  side  of  the  heart  is  over-distended  with 
blood,  and  the  surgeon  in  desperate  cases  may  tap  the  right 


240  MODERN  SURGERY. 

auricle  (see  Paracentesis  Auriculi).  Pericardial  effusion,  if 
severe,  calls  for  tapping  or  aspiration,  and  purulent  peri- 
carditis demands  incision  and  drainage. 

Wounds  and  Injuries. — The  heart  may  rupture  and 
cause  instant  death,  but  slight  wounds  may  not  prove  fatal. 
A  wound  of  the  heart  causes  hemorrhage,  usually  copious, 
but  owing  to  the  interlocking  of  muscular  fibers  the  hemor- 
rhage is  often  slight ;  the  pericardium  may  be  injured  by  frag- 
ments of  a  fractured  rib.  If  bleeding  into  the  pericardial  sac 
takes  place,  the  signs  of  a  pericardial  effusion  become  mani- 
fest. Pain  is  constant,  and  attacks  of  syncope  are  the  rule. 
Death  is  apt  to  occur  suddenly  from  shock,  hemorrhage,  and 
inability  of  the  heart  to  contract  because  of  the  severed 
fibers,  or  inability  of  the  heart  to  dilate  because  of  the 
pressure  of  blood  in  the  pericardial  sac.  If  a  wound  of 
the  pericardium  or  heart  does  not  cause  death  in  the  first 
day  or  two,  inflammation  follows  (traumatic  pericarditis  or 
carditis). 

Treatment. — The  treatment  of  heart-wounds  consists  of 
recumbency  and  lowering  of  the  head.  The  body  is  sur- 
rounded with  hot  bottles,  opium  is  given  in  small  doses,  and 
stimulants  are  applied  in  moderation,  but  never  to  excess. 
An  attempt  must  be  made  to  suture  the  wounds  in  the  heart 
and  pericardium.  Access  can  be  gained  by  resecting  one  or 
more  ribs.  The  wounds  should  be  sutured  with  silk.  Rahn 
sutured  a  wound  of  the  heart  and  packed  the  pericardium 
with  gauze,  and  the  patient  recovered.  Parrozzani  successfully 
sutured  a  wound  of  the  ventricle.  Williams  reports  recovery 
after  a  stab-wound  of  the  heart,  the  pericardium  having  been 
sutured.  Fareni  sutured  a  stab-wound  of  the  left  ventricle, 
and  the  patient  lived  several  days.  Cappelan  sutured  a  wound 
of  the  heart,  and  the  patient  lived  two  and  one-half  days. 
Traumatic  carditis  or  pericarditis  is  treated  in  the  same  way 
as  idiopathic  cases.  Pus  in  the  pericardial  sac  should  be 
evacuated  by  resection  of  the  fourth  left  costal  cartilage  and 
incision  of  the  pericardium  (Von  Eiselberg's  case).  Dalton 
has  sutured  the  pericardium. 

Phlebitis,  or  Inflammation  of  a  Vein. — Phlebitis  may 
be  plastic,  or  it  may  be  piiriilcnt.  Plastic  phlebitis,  while  occa- 
sionally due  to  gout,  to  a  febrile  malady,  or  to  some  other 
constitutional  condition,  usually  takes  its  origin  from  a  wound 
or  other  injury,  from  the  extension  to  the  vein  of  a  peri- 
vascular inflammation,  or  in  the  portal  region  from  an  em- 
bolus. Varicose  veins  are  particularly  liable  to  phlebitis. 
When  phlebitis    begins   a  thrombus  forms    because  of  the 


DISEASES  AND   INJURIES   OF  HEART  AXD    VESSELS.     24 1 

destruction  of  the  endothelial  coat,  and  this  clot  may  be  ab- 
sorbed or  organized.  Suppurative  phlebitis  is  a  suppurative 
inflammation  of  a  vein,  arising  by  infection  from  suppurating 
perivascular  tissues  (infective  thrombophlebitis).  It  is  most 
frequently  met  with  in  cellulitis  or  phlegmonous  erysipelas, 
may  arise  in  the  lateral  sinus  as  a  result  of  mastoid  suppura- 
tion, or  in  the  liver  from  appendicitis  or  phlebitis  of  the 
rectal  veins.  A  thrombus  forms,  the  vein-wall  suppurates,  is 
softened  and  in  part  destroyed,  and  the  clot  becomes  puru- 
lent. No  bleeding  occurs  when  the  vein  ruptures,  as  a  barrier 
of  clot  keeps  back  the  blood-stream.  The  clot  of  suppura- 
tive phlebitis  cannot  be  absorbed  and  cannot  organize.  Septic 
phlebitis  causes  pyemia,  and  the  infected  clots  of  pyemia 
cause  phlebitis. 

Symptoms. — The  symptoms  of  phlebitis  are  pain,  tender- 
ness in  and  around  a  vein,  discoloration  over  it,  and  solid 
edema  below  the  seat  of  the  disease.  '  Suppurative  phlebitis 
causes  the  constitutional  symptoms  of  pyemia  (p.  138). 

Treatment. — The  treatment  of  aseptic  phlebitis  comprises 
rest  in  bed,  bandaging  and  elevation  of  the  part,  and  the  local 
use  of  lead-water  and  laudanum  or  ichthyol.  Hot  fomenta- 
tions are  used  later  in  the  case.  The  danger  is  embolism  ; 
hence  massage  and  movement  are  dangerous.  When  a  vein 
is  involved  in  pyophlebitis  or  septic  thrombophlebitis  ligate, 
if  possible,  above  and  below  the  clot,  open  the  vessel,  and 
wash  out  the  purulent  mass.  This  plan  of  treatment  is 
always  to  be  applied  in  infective  thrombophlebitis  of  the 
lateral  sinus  (p.  564).  The  constitutional  treatment  is  that  of 
pyemia. 

Varicose  Veins,  Phlebectasis,  Phlebectasia,  or 
Varix. — Definition  and  Causes. — Varicose  veins  are  un- 
natural, irregular,  and  permanently  dilated  veins  which 
elongate  and  pursue  a  tortuous  course.  This  condition  is 
very  common,  and  20  per  cent,  of  adults  exhibit  it  in  some 
degree  in  one  region  or  another.  The  causes  of  varicose 
veins  are  obstruction  to  venous  return  and  weakness  of 
cardiac  action,  which  lessens  the  propulsion  of  the  blood- 
stream. 

Varicose  veins  may  occur  in  any  portion  of  the  body,  but 
are  chiefly  met  with  on  the  inner  side  of  the  lower  extremity, 
in  the  spermatic  cord,  and  in  the  rectum.  Varix  in  the  leg 
is  met  with  during  and  after  pregnancy  and  in  persons  who 
stand  upon  their  feet  for  long  periods.  It  especially  appears 
in  the  long  saphenous,  which,  being  subcutaneous,  has  no 
muscular  aid  in  supporting  the  blood-column  and  in  urging 

16 


242  MODERN  SURGERY. 

it  on.  The  deep  as  well  as  the  superficial  veins  may  become 
varicose.  Verneuil  maintained  that  varix  of  the  superficial 
veins  was  almost  always  secondai'y  to  varix  of  the  deep 
veins.  By  the  term  "  caput  medusae  "  are  meant  varicose 
veins  radiating  from  the  umbilicus.  The  veins  of  the  esopha- 
gus may  become  varicose,  and  this  malady  is  rarely  recognized. 
Varicose  veins  are  in  rare  instances  congenital ;  they  are  most 
often  seen  in  the  aged,  but  usually  begin  between  the  ages 
of  twenty  and  forty.  They  are  more  common  in  women 
than  in  men  because  of  the  influence  of  pregnancy. 

Varix  of  the  spermatic  cord  is  known  as  "  varicocele." 
It  is  apt  to  appear  about  the  time  of  puberty,  and  most  adult 
men  have  at  least  a  slight  varicocele.  Varix  is  more  likely 
to  appear  in  the  left  spermatic  vein  than  in  the  vein  of  the 
right  side,  because  the  left  spermatic  vein  has  no  valves 
(Brinton). 

Varix  of  the  veins  of  the  rectum  is  known  as  "  hemor- 
rhoids "  or  "  piles,"  which  are  caused  by  obstruction  to  the 
upward  flow  in  the  hemorrhoidal  veins,  either  by  obstructive 
liver  disease,  enlargement  of  the  uterus  or  prostate,  or  the 
presence  in  the  rectum  of  fecal  masses  in  a  person  habitually 
constipated. 

A  vein  under  pressure  usually  dilates  more  at  one  spot  than 
at  another,  the  distention  being  greatest  back  of  a  valve  or 
near  the  mouth  of  a  tributary.  The  valves  become  incom- 
petent and  the  dilatation  becomes  still  greater.  Callender 
has  pointed  out  that  varix  is  apt  to  begin  where  the  deep 
vessels  join  the  superficial  veins.  At  this  point  Treves 
says  three  forces  meet,  the  blood-column  above,  the  valve 
below,  and  the  force  of  the  blood-current.  At  this  point  the 
vein-wall  dilates,  and  from  this  dilatation  the  blood-current  is 
affected  and  causes  another  dilatation  higher  up  (Agnew). 
The  vein-wall  may  become  fibrous,  but  usually  it  is  thin  and 
often  ruptures.  The  veins  not  only  dilate,  but  they  also 
become  longer,  and  hence  do  not  remain  straight,  but  twist 
and  turn  into  a  characteristic  form.  Varicose  veins  are  apt 
to  cause  edema,  and  the  watery  elements  in  the  tissues  cause 
eczema  of  the  skin.  When  eczema  is  once  inaugurated  ex- 
coriation is  to  be  expected.  Infection  of  an  excoriated  area 
produces  inflammation,  suppuration,  and  an  ulcer. 

The  skin  over  varicose  veins  in  the  leg  is  often  discolored  by 
pigmentation  due  to  the  red  blood-cells  having  escaped  from 
the  vessel  and  been  broken  up.  The  tissues  around  a  vari- 
cose vein  become  atrophied  from  pressure,  and  there  is 
often   met  with  a  very  large  vein  whose  thin  walls  are  in 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     243 

close  contact  with  skin.  In  this  condition  rupture  and 
hemorrhage  are  probable.  V^aricose  veins  are  apt  to  inflame, 
and  thrombosis  frequently  occurs. 

Treatment. — The  treatment  of  varix  may  be  palliative  or 
curative,  but  whichever  is  followed  endeavor  first  to  remove 
the  exciting  cause.  In  palliative  treatment,  attend  to  the 
general  health,  keep  up  the  force  and  activity  of  the  circu- 
lation, and  prevent  constipation.  Recommend  the  patient 
to  exercise  in  the  open  air  and  to  lie  down,  if  possible,  every 
afternoon.  Locally,  in  varix  of  the  leg,  order  a  flannel  roller 
or  a  Martin  rubber  bandage  to  support  the  veins  and  drive 
the  blood  into  the  deeper  vessels  which  have  muscular  sup- 
port. The  use  of  a  rubber  pad  filled  with  glycerin  and 
applied  over  the  saphenous  vein  so  as  to  support  the  blood- 
column  and  act  as  a  valve,  has  been  recommended.  Locally, 
in  varicocele,  pour  cold  water  upon  the  scrotum  twice  a  day 
and  order  the  patient  to  wear  a  suspensory  bandage.  Lo- 
cally, in  hemorrhoids,  use  astringent  suppositories  (p.  715). 
The  curative  or  radical  treatment  of  varix  of  the  leg  com- 
prises ligation  with  exdsion  of  part  of  the  vein,  exposure 
and  ligation  of  the  vein,  multiple  subcutaneous  ligatures  of 
catgut,  acupressure-pins  with  twisted  sutures,  injection  of 
pure  carbolic  acid  into  the  perivascular  structures,  circular 
incision  around  the  leg  (see  Operations  upon  Vessels). 

Nevus. — (See  Tumors.) 

Arteritis,  or  inflammation  of  an  artery,  is  acute  or  c/ironic. 

Acute  arteritis  may  result  from  injury  or  from  extension 
of  inflammation  from  the  perivascular  tissues.  This  latter 
mode  of  origin  is  uncommon,  as  arteries  are  very  resistant 
to  the  spread  of  inflammation,  but  we  meet  with  it  some- 
times in  suppurating  areas.  In  a  suppurating  acute  arteritis 
the  coats  ulcerate  through,  but  hemorrhage  rarely  occurs 
unless  a  considerable  portion  of  the  vessel  sloughs.  Septic 
emboli  lodging  in  the  arterial  system  produce  acute  arte- 
ritis. This  is  seen  during  the  progress  of  ulcerative  endo- 
carditis. 

Chronic  arteritis  produces  "atheroma."  It  is  due  to 
increase  of  blood-pressure  from  hard  work,  strains,  heart- 
disease,  or  contracted  kidney.  It  is  especially  common  in 
drunkards  in  the  larger  arteries.  It  is  often  met  with  in 
drunkards,  but  occurs  in  aged  men  who  never  drank.  It  is 
a  true  saying  that  "  A  man  is  as  old  as  his  arteries."  In 
chronic  arteritis  exudation  of  serum  and  migration  of  leuko- 
cytes take  place  beneath  the  intima,  and  a  like  exudation  soon 
becomes  manifest  in  the  media,  in  the  adventitia,  and  even  in 


244  MODERN  SURGERY. 

the  sheath.  Embryonic  tissue  is  formed,  which  may  undergo 
resolution,  may  become  fibrous  tissue  (arterial  sclerosis),  or 
may  undergo  fatty  degeneration  (atheroma).  When  fatty  de- 
generation occurs  the  endothelium  is  destroyed,  the  vessel- 
wall  is  damaged,  and  the  blood  obtains  access  to  the  deeper 
coats.     Calcareous  change  may  follow  fatty  degeneration. 

An  atheromatous  artery  is  rigid  and  inelastic,  and  the 
parts  it  supplies  are  cold,  congested,  and  ill-nourished. 
Atheroma  is  a  frequent  cause  of  thrombosis,  aneurysm,  senile 
gangrene,  and  apoplexy.  Syphilitic  arteritis  is  characterized 
by  an  enormous  growth  of  granulation-tissue  from  the  inner 
coats  (obliterative  arteritis)  of  arteries  of  small  size.  Calci- 
fication of  an  artery  may  be  secondary  to  fatty  change,  or 
may  occur  primarily  from  deposit  of  lime  salts  in  the  middle 
coat.  Periarteritis  is  inflammation  of  the  sheath  and  outer 
coat.  An  acute  arteritis  is  always  local,  but  a  chronic 
arteritis  may  be  general. 

Treatment  of  acute  arteritis  consists  of  rest,  elevation 
and  relaxation,  the  application  of  tincture  of  iodin,  and  the 
use  of  lead-water  and  laudanum.*  Hot  fomentations  are 
applied  later.  Abscesses  are  opened  and  drained.  Inter- 
nally, treat  any  diathesis  (rheumatic,  gouty,  or  syphilitic), 
maintain  kidney  secretion,  quiet  the  circulation,  and  employ 
a  non-stimulating  diet.  The  part  must  be  kept  quiet,  as 
rough  movement  would  tend  to  rupture  the  vessel. 

Treatment  of  Chronic  Arteritis. — In  treating  chronic 
arteritis,  endeavor  to  antagonize  the  dangers  to  which  the 
patient  is  obviously  liable.  Stop  alcohol  as  a  beverage, 
though  a  little  whiskey  may  be  taken  at  meals  to  aid  di- 
gestion. Maintain  the  activity  of  the  skin  by  daily  baths, 
and  of  the  kidneys  by  diuretic  waters.  The  contents  of  the 
bowels  are  to  be  kept  soft.  The  diet  is  to  be  plain  and 
is  to  contain  a  minimum  of  nitrogen.  If  syphilis  has  existed, 
occasional  courses  of  iodid  are  to  be  urged.  If  the  arterial 
tension  at  any  time  becomes  inordinately  high,  give  nitro- 
glycerin. One  danger  is  apoplexy  ;  hence  excitement  and 
violent  exercise  are  to  be  avoided.  Another  danger  is  senile 
gangrene ;  hence  the  patient  should  wear  woollen  stockings, 
put  a  hot  bottle  to  his  feet  at  night,  and  be  careful  to  avoid 
injuring  his  toes  or  feet,  especially  when  cutting  his  corns. 
When  a  patient  with  atheroma  has  dyspnea  and  is  of  a 
livid  color,  or  when  the  arterial  tension  is  very  high,  a 
moderate  bloodletting  (sixteen  to  eighteen  ounces)  does  good. 
Still  another  danger  is  aneurysm,  which  may  appear  suddenly 
from  rupture  or  gradually  from  progressive  distention. 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     245 

Aneurysm. — An  aneurysm  is  a  pulsating  sac  containing 
blood  and  communicating  with  the  cavity  of  an  artery. 
Some  restrict  the  term  "  true  aneurysm  "  to  a  condition  of 
dilatation  involving  all  the  coats  of  the  vessel.  We  shall 
consider,  with  Heath,  a  true  aneur>^sm  to  be  one  in  which 
the  blood  is  included  in  one  or  more  of  the  arterial  coats, 
and  a  false  aneurysm  to  be  a  condition  in  which  the  vessel 
has  ruptured  or  has  atrophied  and  the  aneurysmal  wall  is 
formed  by  a  condensation  of  the  perivascular  tissues. 

Forms  of  Aneurysm. — The  following  forms  of  aneurj'sm 
are  recognized : 

1.  True  aneurysm — one  whose  sac  is  formed  of  one  or 
more  arterial  coats. 

2.  False  aueurysin — one  whose  sac  is  formed  of  condensed 
perivascular  tissues  and  contains  no  arterial  coat. 

3.  Traumatic  aneurysm — a  false  aneur>'sm  due  to  traumatic 
rupture  some  time  before,  the  blood  being  in  a  sac  of  tissue 
and  all  wound  being  healed. 

4.  Fusiform  aneurysm — a  variety  of  true  aneurysm,  the 
sac  being  spindle-shaped. 

5.  Consecutive  aneurysm — a  sacculated  aneur)^sm  diffused 
by  rupture,  or  a  false  aneurysm  due  to  gradual  destruction 
or  atrophy  of  a  true  aneurysmal  sac  or  to  vascular  rup- 
ture. 

6.  Sacculated  aneurysm — a  common  form  of  aneurysm,  in 
which  the  dilatation  is  like  a  pouch,  arising  from  a  part  of 
the  arterial  circumference  and  joining  the  lumen  of  the  vessel 
by  an  aperture. 

7.  Dissecting  aneurysm — a  pouch-like  dilatation,  due  to  the 
blood  which,  passing  through  an  aperture  in  the  intima, 
enters  between  the  media  and  adventitia  and  dissects  them 
apart.  It  may  or  may  not  join  the  lumen  of  the  artery  at 
another  point  by  a  fresh  aperture  in  the  intima. 

8.  Arteriovenous  aneurysm,  which  is  divided  into  aneur- 
ysmal varix,  or  Pott's  aneurysm,  where  there  is  direct  com- 
munication between  a  vein  and  an  artery,  and  varicose  aneur- 
ysm, where  there  is  communication  between  an  artery  and  a 
vein  by  means  of  an  interposed  sac. 

9.  Acute  aneurysm — a  cavity  in  the  walls  of  the  heart, 
which  cavity  communicates  with  the  interior  of  this  organ, 
and  which  is  due  to  suppuration  in  the  course  of  acute  endo- 
carditis or  myocarditis. 

10.  Aneurysm  by  anastomosis  (see  Angeiomata). 

1 1.  Aneurysm  of  bone — an  inaccurate  clinical  term  used  to 
designate  a  pulsatile  tumor  of  bone. 


246  MODERN  SURGERY. 

12.  Circumscribed  aneurysm — when  the  blood  is  circum- 
scribed by  distinct  walls. 

13.  Cirsoid  aneurysm — a  mass  of  dilated  and  elongated 
arteries  shaped  like  varicose  veins  and  pulsating  with  each 
heart-beat. 

14.  Cylindrical  aneurysm — a  dilatation  of  the  same  dimen- 
sions for  a  considerable  space. 

15.  Embolic  or  capillary  aneurysm — dilatation  of  terminal 
arteries  due  to  emboli. 

16.  Spontaneous  aneiwysm — non-traumatic  in  origin. 

17.  Miliary  aneurysm — a  minute  dilatation  of  an  arteriole. 

18.  Secondary  aneurysm — one  which,  after  apparent  cure, 
again  pulsates,  the  blood  entering  by  means  of  the  anasto- 
motic circulation. 

19.  Verminous  aneurysm — one  containing  a  parasite.  This 
form  of  aneurysm  is  met  with  in  the  mesenteric  artery  of  the 
horse. 

The  sac  of  a  sacculated  aneurysm  is  at  first  composed  of 
at  least  two  of  the  arterial  coats,  reinforced  by  the  sheath 
and  perivascular  tissues.  After  a  time  the  blood-pressure 
distends  the  sac,  and  the  inner  and  middle  coats  either  stretch 
with  interstitial  growth  or — what  is  more  common — are  worn 
away  and  lost.  When  all  the  coats  are  lost,  and  the  blood 
is  sustained  only  by  the  sheath  and  surrounding  tissue,  a 
true  aneurysm  becomes  a  diffused  or  consecutive  aneurysm, 
the  limiting  tissues  and  sheath  being  condensed,  thickened, 
and  glued  together.  This  limiting  process  is  deficient  in  the 
brain ;  hence  cerebral  aneurysms  break  soon  after  their 
formation.  When  all  the  arterial  coats  are  lost,  the  blood- 
pressure,  acting  on  the  tissues,  finds  some  spots  less  resistant 
than  others,  the  blood  follows  the  lines  of  least  resistance, 
the  aneurysm  grows  with  great  rapidity,  and  soon  ruptures. 

An  aneurysm  may  rupture  into  a  cavity  (pleura,  pericar- 
dium, or  peritoneum),  into  the  perivascular  tissues,  or  through 
the  skin.  Rupture  into  the  tissues  may  produce  pressure- 
gangrene.  When  rupture  occurs  through  the  skin,  the  hem- 
orrhage is  not  often  instantly  fatal,  but  during  several  days 
constantly  recurs  in  larger  and  larger  amounts.  The  pressure 
of  an  aneurysmal  sac  causes  atrophy  of  tissues,  hard  and  soft, 
bones  and  cartilages  being  as  easily  destroyed  as  muscles  and 
fat.  Sometimes  the  perivascular  tissues  inflame  and  suppu- 
rate, and  the  sac  is  opened  rapidly  by  sloughing.  An  aneurysm 
usually  progresses  toward  rupture,  the  slowest  in  this  progres- 
sion being  the  fusiform  dilatations,  which  may  exist  for  many 
years,  but  which  finally  eventuate  in  the  sacculated  variety. 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     247 

In  some  rare  instances  there  takes  place  spontaneous  cure, 
which  may  result  from  laminated  fibrin  being  deposited  upon 
the  walls  of  the  sac  as  the  blood  circulates  through  it.  This 
laminated  fibrin  is  known  as  an  "  active  clot,"  and  eventually 
fills  the  sac.  The  weaker  and  slower  the  blood-stream,  the 
greater  is  the  tendency  to  the  formation  of  an  active  clot ; 
hence  any  agent  impeding,  but  not  abolishing,  the  circulation 
aids  in  the  deposition.  This  weakening  and  slowing  of  cir- 
culation may  be  brought  about  by  great  activity  of  the  col- 
lateral circulation  deviating  most  of  the  blood  away  from  the 
area  of  disease.  Sometimes  a  clot  breaks  off  from  the  sac- 
wall  and  plugs  the  artery  beyond  the  dilatation,  and  the  an- 
astomotic vessels,  enlarging,  divert  the  blood-stream.  A  large 
aneurysm,  falling  over  by  its  own  weight  upon  the  vessel 
above  the  mouth  of  the  sac,  may  diminish  the  blood-stream. 
The  development  of  another  aneurysm  upon  the  same  vessel 
nearer  to  the  heart  weakens  the  circulation  in  and  may  cure 
the  older  one.  Inflammation  occasionally  forms  a  clot.  The 
tissues  about  an  aneurysm  tend  to  contract  when  arterial 
force  is  lessened ;  hence  tissue-pressure  may  more  than 
counteract  blood-pressure  when  the  circulation  is  feeble. 
Clotting  of  the  blood  contained  within  a  sac,  circulation 
through  the  aneurysm  having  ceased,  causes  a  passive  clot. 
A  passive  clot,  which  occasionally  cures,  may  arise  from  a 
twisting  of  the  neck  of  the  sac,  preventing  the  passage  of 
blood ;  from  the  lodgement  of  a  clot  in  the  mouth  of  the 
sac ;  and  from  inflammation.  Spontaneous  cure  is,  unfortu- 
nately, very  rare. 

Causes  of  Aneurysm. — Gradual  distention  of  arterial  coats 
which  are  in  a  condition  of  arterial  sclerosis,  or  local  loss  of 
resisting  power  due  to  atheroma,  may  cause  aneurysm.  Hence 
the  causes  of  sclerosis  and  atheroma  are  also  causes  of  aneur- 
ysm. The  principal  cause  of  aneurysm  is  increased  blood- 
pressure.  This  increase  may  be  brought  about  by  severe 
labor ;  by  sudden  strains,  as  in  lifting ;  by  violent  efforts,  as 
in  rowing  in  a  boat-race ;  by  chronic  interstitial  nephritis  ;  by 
hypertrophy  of  the  heart ;  by  alcoholic  inebriety ;  and  by 
syphilis.  Arterial  disease  is  commonest  in  the  larger  vessels 
and  in  the  aged,  but  it  may  occur  in  youth.  When  an  aneur- 
ysm follows  a  strain,  it  may  be  due  to  laceration  of  the  media 
and  loss  of  resistance  at  a  narrow  point.  The  intima  may 
lacerate,  permitting  the  blood  to  come  in  contact  with  the 
media  or  causing  blood  to  diffuse  between  the  coats  (dissect- 
ing aneurysm).  An  embolus  which  lodges  may  cause  an 
aneurysm  on  its  proximal  side.     The  embolus,  if  infective. 


248  MODERN  SURGERY. 

causes  softening,  and  if  calcareous  causes  laceration  (Osier). 
Colonies  of  micrococci  may  cause  aneurysm/  The  parasite 
strongyltis  armatiis  causes  aneurysm  of  the  mesenteric  arteries 
in  horses.  Suppuration  around  a  vessel  weakens  its  coats  and 
tends  to  aneurysm  by  inducing  acute  arteritis  and  softening. 
Sometimes  an  individual  develops  multiple  aneurysms  the 
origins  of  which  are  absolutely  unknown. 

TJic  constituent  parts  of  ait  aneurysm  are  (i)  the  wall  of  the 
sac ;  (2)  the  cavity ;  (3)  the  mouth ;  and  (4)  the  contents. 

Symptoms  of  Aneurysm. — An  oval  or  globular,  soft, 
elastic,  and  pulsatile  protrusion,  develops  in  the  Hne  of  an 
artery.  It  is  usually  quite  evident  to  the  touch  that  the 
sac  contains  fluid,  but  sometimes  in  old  aneurysms  it  feels 
firm  or  even  hard,  because  of  the  deposit  of  fibrin  upon  its 
inner  surface.  In  a  partially  consolidated  aneurysm  pulsation 
may  be  slight  or  even  inappreciable.  This  protrusion  in- 
stantly ceases  to  pulsate  and  almost  disappears  on  making 
firm  pressure  on  the  artery  above.  On  relaxing  the  pressure 
the  pulsatile  enlargement  at  once  reappears.  Direct  pressure 
upon  the  tumor  may  cause  it  to  almost  disappear.  Pressure 
upon  the  artery  below  causes  the  tumor  to  enlarge.  The 
pulsation  is  expansile — that  is,  it  expands  in  all  directions — 
and  if  an  index  finger  be  laid  on  each  side  of  the  tumor  so 
that  their  points  nearly  touch,  each  pulsation  not  only  lifts 
the  fingers,  but  it  also  separates  them.  On  placing  a  stetho- 
scope over  the  aneurysm  or  over  the  vessel  below  the  aneur- 
ysm there  is  imparted  to  the  ear  a  distinct  bruit  which  travels 
in  the  direction  of  the  blood-stream,  is  systolic  in  time,  and 
is  usually  blowing  in  character.  In  some  cases  bruit  is  absent 
(when  a  sacculated  aneurysm  has  a  very  small  mouth,  when 
the  circulation  is  tranquil,  or  when  the  sac  is  full  of  blood 
and  clot).  When  bruit  is  absent  it  may  sometimes  be  de- 
veloped by  muscular  exercise  or  raising  the  affected  limb 
(Hollo way).  In  rare  cases  there  may  be  a  double  bruit.  Occa- 
sionally in  fusiform  aortic  aneurysm  linked  with  aortic  regur- 
gitation a  diastolic  bruit  exists.  A  bruit  is  arrested  by  press- 
ing upon  the  artery  between  the  aneurysm  and  the  heart.^ 
The  skin  over  an  aneurysm  may  be  normal  or  discolored, 
and  may  slough  or  ulcerate.  Aneurysm  of  an  extremity  is 
apt  to  produce  edema  and  varicose  veins,  because  of  pressure 
upon  large  veins  and  loss  of  vis  a  tergo  in  circulation.  The 
muscles  feel  tired,  and  sometimes  there  is  pain.  In  internal 
aneurysms  pressure-symptoms  are  marked.    Thoracic  aneur- 

1  See  Osier  on  Malignant  Endocarditis. 

2  Holloway  on  "  Aneurysm,"  in  Park's  Siti-gery  by  American  Authors. 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     249 

ysm  causes  intercostal  pain  ;  iliac  aneurysm  causes  pain  in 
the  thigh.  Aneurysm  of  the  aorta  presses  upon  the  pneu- 
mogastric  nerve,  causing  spasmodic  dyspnea,  and  upon  the 
recurrent  laryngeal,  causing  loss  of  voice  and  paralysis  of  all 
the  muscles  of  the  larynx  except  the  cricothyroid.  The 
pulse  below  an  aneurysm  is  weaker  than  the  pulse  of  the  cor- 
responding part  of  the  opposite  limb.  This  is  well  shown  by 
the  sphygmograph,  the  tracings  being  rounded  without  a 
sudden  rise  or  an  abrupt  fall  (Fig.  39).     The  evidences  of 


Fig.  39. — Radial  pulse-tracings  in  aneurysm  of  right  brachial  artery  :   i,  left  radial  pulse  ; 
2,  right  radial  pulse  (after  Mahomed). 

rupture  are  loss  of  distinctness  of  outline  and  increase  in  area 
of  the  tumor,  weakening  or  disappearance  of  both  bruit  and 
pulsation,  severe  pain,  edema  and  coldness  of  the  surface 
and  possibly  syncope.  External  hemorrhage  may  arise  ;  the 
tissues  may  become  extensively  infiltrated  with  blood ;  slough- 
ing or  gangrene  may  ensue.  Death  is  frequent,  and  only  in 
very, rare  cases  does  spontaneous  cure  take  place. 

Diagnosis. — A  cyst  or  abscess  over  a  vessel  may  show 
transmitted  pulsation  which  is  not  expansile,  and  the  tumor 
does  not  disappear  on  pressure  above  it.  The  pulsation 
ceases  when  the  growth  is  lifted  off  the  vessel,  or  when  the 
position  is  changed  so  as  to  permit  it  to  fall  away  from  the 
vessel.  There  is  no  true  bruit,  and  the  history  is  widely  dif- 
ferent. A  growth  under  a  vessel  may  lift  the  vessel  and 
simulate  an  aneurysm,  but  the  pulsation  is  not  noted  in  the 
entire  growth,  the  growth  does  not  disappear  on  proximal 
pressure,  and  there  is  only  a  false,  and  never  a  true,  bruit. 
The  larger  the  growth  the  less  is  the  pulsation  due  to  press- 
ure upon  the  vessel.  A  sarcoma,  especially  a  soft  sarcoma 
attached  to  the  bone,  and  also  a  nevoid  mass,  pulsate  and  often 
have  a  bruit ;  the  tumor  never  disappears  from  proximal  press- 
ure, though  it  may  slowly  diminish  in  size,  to  gradually  en- 
large again  when  pressure  is  withdrawn.  These  growths  do 
not  feel  fluid,  and  are  rarely  circumscribed.  An  aneurysm 
may  cease  to  pulsate  from  consolidation  leading  to  cure,  or 
from  rupture.     Rupture  of  a  large  aneurysm  into  a  cavity 


250  MODERN  SUR  GER  V. 

induces  deadly  pallor,  syncope,  and  rapid  death.  Rupture  of 
an  aneurysm  of  an  extremity  into  the  tissues  is  made  mani- 
fest by  a  sensation  of  something  breaking,  by  pain,  by  sud- 
den increase  in  size,  by  diminution  or  absence  of  bruit  and 
pulsation,  by  absence  of  pulse  below  the  aneurysm,  by  swell- 
ing and  coldness  of  the  limb,  and  by  shock. 

Treatment. — In  inoperable  aneurysms  gejieral,  medical, 
and  dietetic  treatment  must  be  tried.  It  consists  chiefly  in 
rest  in  bed  to  diminish  the  rapidity  and  force  of  the  circu- 
lation and  favor  fibrinous  deposit.  Tuffnell's  plan  is  to 
reduce  the  heart-beats  by  rest  and  mental  quiet,  and  to 
rigidly  restrict  the  diet  so  as  to  diminish  the  total  amount 
of  blood  and  render  it  more  fibrinous.  Liquids  are  re- 
stricted in  amount,  and  the  patient  lives  for  twenty-four 
hours  upon  four  ounces  of  bread,  a  very  little  butter,  eight 
ounces  of  milk,  and  three  ounces  of  meat.  Pursue  this  plan 
for  several  months  if  possible,  or  employ  it  for  several  weeks 
at  a  time  over  and  over  again.  There  can  be  no  doubt  that 
Tuffnell's  treatment  sometimes  cures  by  decidedly  lowering 
the  blood-pressure.  Valsalva  long  ago  suggested  rest, 
occasional  bleeding,  and  a  diet  just  above  the  point  of  star- 
vation. In  many  cases  of  aneurysm  the  patient  may  be 
permitted  to  go  about,  taking  his  time  about  everything  and 
avoiding  work,  worry,  and  excitement.  The  diet  is  low  and 
non-stimulating,  and  the  bowels  must  be  maintained  in  a 
loose  condition. 

lodid  of  potassium  in  doses  of  20  grains  undoubtedly 
does  good,  and  not  only  in  syphilitic  cases.  It  seems  to 
lower  the  blood-pressure.  Balfour  taught  that  it  thickened 
the  sac.  Osier  says  it  relieves  the  pain.  Iron,  acetate  of 
lead,  and  ergotin  are  prescribed  by  some.  Digitalis  is 
contraindicated,  as  it  raises  the  blood-pressure.  S.  Solis 
Cohen  has  used  with  some  success  the  hydrated  chlorid 
of  calcium.  Morphin  and  bromid  of  potassium  are  occa- 
sionally useful  to  tranquillize  the  circulation,  allay  pain,  or 
secure  sleep.  Aconite  and  veratrum  viride  have  long  been 
employed.  Other  expedients  are :  the  kneading  of  the  sac 
to  release  a  clot,  in  the  hope  that  it  will  plug  the  mouth  of 
the  sac  or  the  artery  beyond  it — this  is  dangerous  ;  elec- 
tricity ;  electrolysis ;  the  injection  of  an  astringent  liquid ; 
the  insertion  of  a  fine  aspirating-needle  and  the  pushing 
through  it  into  the  sac  of  a  large  quantity  of  silver  wire,  in 
the  hope  that  it  will  aid  in  whipping  out  fibrin.  Some 
physicians  have  inserted  needles  and  horse-hair. 

Even  in  an  operable  case  diet  and  rest  are  of  importance. 


D/SE.-iSES  AND   IXJURIES   OF  HEART  AND    VESSELS.     25 1 

The  patient  should  be  in  bed  for  a  number  of  days  before 
operation,  the  daily  diet  consisting  of  ten  or  twelve  ounces 
of  solid  food  with  a  pint  of  milk.  If  the  circulation  is  very 
active,  use  aconite  and  allay  pain  by  morphin. 

Treatment  by  Pressure. — Iiistrinnental  pressure  is  made  by 
applying  two  Signorini  tourniquets  or  some  specially  devised 
apparatus  to  limit  the  flow  of  blood  through  an  aneurysm 
without  entirely  stopping  it,  the  aneurysmal  sac  being  felt 
to  still  slightly  pulsate.  In  some  situations  Lister's  abdom- 
inal tourniquet  is  applied ;  in  other  regions  we  may  use  Tuff- 
nell's  compress,  which  is  like  a  spring  truss  and  is  strapped 
in  place.  A  weight  suspended  over  the  artery  and  resting 
part  of  its  weight  upon  the  vessel  has  occasionally  brought 
about  cure.  These  instruments  can  be  worn  for  from  twelve 
to  sixteen  hours  at  a  time  ;  usually  they  are  removed  to  permit 
sleep  and  reapplied  the  next  day,  and  so  on  for  several 
days.  Before  applying  the  compress  be  sure  the  sac  is 
full  of  blood,  and  render  this  certain  by  applying  for  a  few 
minutes  distal  compression.  This  method  may  cure,  but  it 
is  very  painful.  It  cannot  be  used  successfully  in  treating 
aneurysm  of  the  axillary,  subclavian,  or  carotid.  It  aids  in 
the  formation  of  an  acti\-e  clot. 

Digital  pressure,  made  with  the  thumb  aided  by  a  weight, 
and  maintained  for  many  hours  by  a  relay  of  assistants,  has 
cured  many  cases.  This  method  may  be  used  alone  or  may 
be  used  as  an  accessory  to  instrumental  pressure.  Its  chief 
field  is  in  the  treatment  of  aneurysm  for  which  other  methods 
are  inapplicable  (orbit  and  root  of  neck).  It  entirely  cuts 
off  the  blood  and  promotes  the  formation  of  a  passive  clot. 
If  cure  does  not  take  place  in  three  days,  abandon  pressure. 
It  must  often  be  abandoned  because  of  pain. 

Direct  pressure  upon  the  sac  has  been  used  in  aneurysm 
of  the  popliteal  arter}-,  the  pressure  being  obtained  by  flexing 
the  leg ;  and  in  aneur>'sm  of  the  brachial  artery  pressure  has 
been  applied  at  the  bend  of  the  elbow  by  flexing  the  elbow. 
The  pressure  of  a  hollow  rubber  ball  has  been  used  in  aneur- 
ysm of  the  subclavian. 

Rapid  pressure  completely  arrests  the  passage  of  blood 
through  the  sac  for  a  limited  time,  and  is  applied  while  the 
patient  is  under  the  influence  of  an  anesthetic.  Take,  for 
example,  a  case  of  popliteal  aneurj^sm :  the  patient  is  placed 
under  ether ;  two  Esmarch  bandages  are  used,  one  being  put 
on  the  limb  from  the  toes  to  the  lower  limit  of  the  aneurysm, 
and  the  other  from  the  groin  down  to  the  upper  limit  of  the 
sac,  and   the   Esmarch   band   is   fastened   above    the   upper 


252  MODERN  SURGERY. 

bandage.  This  procedure  stagnates  the  blood  both  in  the 
veins  and  in  the  arteries,  the  sac  remaining  full  of  blood. 
Pressure  is  thus  maintained  for  three  or  four  hours,  and  on 
removing  the  Esmarch  apparatus  a  tourniquet  is  put  on  the 
artery  above  the  aneurysm  and  partly  tightened  to  limit 
the  amount  of  blood  passing  through  and  thus  prevent 
the  washing  away  of  clot.  This  method  of  rapid  pressure 
sometimes  cures  by  forming  a  passive  clot,  but  it  sometimes 
results  in  gangrene.     It  was  devised  by  John  Reid. 

Operative  Treatment:  By  the  Ligature. — Ligation  of  the 
main  artery  is,  as  a  rule,  the  best  procedure.  The  methods 
of  ligation  are — (i)  the  method  of  Antyllus;  (2)  the  method 
of  Anel ;  (3)  the  method  of  Hunter ;  (4)  the  method  of  War- 
drop  ;  and  (5)  the  method  of  Brasdor. 

In  the  method  of  Antyllus  the  sac  itself  is  attacked. 
Hemorrhage  is  controlled  by  the  Esmarch  bandage,  the  sac 
is  opened,  its  contents  turned  out,  and  the  artery  ligated 
immediately  above  and  below  the  sac.  This  method  is 
chiefly  employed  for  traumatic  aneurysms,  as  its  use  in 
aneurysms  from  diseased  vessel-walls  would  mean  that  the 
ligatures  were  probably  applied  upon  diseased  areas  (Fig. 
40).  Syme  suggested  many  years  ago  that  extirpation  was 
the  proper  operation  for  aneurysm  of  the  gluteal,  iliac,  car- 
otid, and  axillary  arteries.  In  some  cases  it  is  the  best 
method. 

The  Metliod  of  Anel. — In  Anel's  method  the  artery  is 
ligated  close  to  and  above  the  sac  (Fig.  41).     It  is  only  used 


Fig.  40. — Old  operation  of  Antyllus  foraneur-      Fig.  41. — Anel's  operation  for  aneurysm  (.^wz. 
ysm  (/4?K.  Text-Book  of  Surgery).  Text-Book  of  Stirgeryi). 

for  traumatic  aneurysms,  and  is  never  employed  when  the 
vessel  is  diseased. 

TJie  Metliod  of  Hunter. — This  operation,  which  is  the 
modern  method  of  ligation,  was  devised  by  the  illustrious 
John  Hunter.  He  recognized  the  fact  that  the  vessel  adja- 
cent to  an  aneurysm  was  apt  to  be  diseased,  and  he  discov- 
ered the  anastomotic  circulation.  Putting  together  these 
two  facts,  he  devised  the  operation  which  goes  by  his  name. 
It  consists  in  applying  a  ligature  between  the  heart  and  the 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     253 

aneurysm,  but  so  far  above  the  sac  that  collateral  branches 
are  given  off  between  it  and  the  point  of  ligation  (Fig.  42). 
This  operation,  which  is  done  upon  a  healthy  area,  does  not 
at  once  cut  off  all  blood,  but  so  diminishes  the  force  and 
frequency  of  the  circulation  that  an  active  clot  forms  within 


ci^s: 


Fig.  42. — Hunter's  operation  for  aneurysm  [Avicrican  Text-Book  of  Surgery). 

the  sac.  Thus  is  lessened  the  danger  of  secondary  hemor- 
rhage and  of  gangrene.  It  is,  as  a  rule,  the  proper  opera- 
tion for  aneurysm.  In  some  cases  pulsation  does  not  return 
after  tightening  the  ligature ;  in  most  cases,  however,  it 
reappears  for  a  time  after  about  thirty-six  hours,  but  is  weak 
and  constantly  diminishing.  Previous  prolonged  compres- 
sion by  enlarging  the  collateral  branches  permits  strong 
pulsation  to  soon  recur  after  ligation,  and  thus  militates 
against  cure ;  hence  it  is  a  bad  plan  to  use  pressure  in  cases 
where  its  success  is  very  uncertain.  Occasionally  after  Hun- 
ter's operation  the  sac  suppurates,  producing  symptoms  like 
those  of  abscess.  When  rupture  takes  place  there  may  be 
no  hemorrhage,  or  profuse  hemorrhage  may  rapidly  kill  the 
patient,  or  hemorrhage  may  recur  again  and  again  until  death 
ensues.  Suppuration  may  occur  between  the  first  and  thirty- 
second  week  after  ligation.^  When  pus  forms  open  freely 
as  we  would  open  an  abscess,  and,  if  no  blood  flows,  treat 
as  an  abscess,  but  have  a  tourniquet  loosely  applied  for  sev- 
eral days  ready  to  screw  up  at  the  first  sign  of  danger.  If 
hemorrhage  occurs,  tie  the  vessel  above  and  below  and  pack 
with  iodoform  gauze,  having  the  tourniquet  ready  to  tighten. 
If  bleeding  recurs,  there  is  no  use  reapplying  the  ligature  and 
there  is  little  use  tying  higher  up.  If  dealing  with  an  extrem- 
ity, amputate  at  once. 

Distal  Ligation. — When  an  aneurysm  is  so  near  the  trunk 
that  Hunter's  operation  is  impracticable,  or  when  the  artery 
on  the  cardiac  side  of  the  tumor  is  greatly  diseased,  distal 
ligation  may  be  employed.  Distal  ligation  forms  a  barrier 
to  the  onflow  of  blood,  collateral  branches  above  the  aneur- 
ysm enlarge,  the  blood-current  is  gradually  diverted,  and 
a  clot  is  formed.  Distal  ligation  is  used  in  some  aneurysms 
*  See  the  famous  case  of  Sir  Astley  Cooper. 


254 


MODERN  SURGERY. 


of  the  aorta,  iliacs,  innominate,  carotids,  and  subclavians.  It 
occasionally  causes  rupture  of  the  sac  of  the  aneurysm. 

The  operation  of  Brasdor  consists  in  tying  the  main  trunk 
some  little  distance  below  the  aneurysm  (Fig.  43).  It  com- 
pletely arrests  circulation  in  the  sac. 

The  operation  of  War  drop  consists  in  tying  one  of  the 
branches  of  the  artery  below  the  aneurysm  (Fig.  44).  It 
partially  arrests  the  circulation  in  the  sac. 

After  ligating  for  aneurysm  by  any  of  these  methods, 
elevate  the  limb,  keep  it  warm,  and  subdue  arterial  excite- 


FiG.  43. — Brasdor's  operation  (Holmes).     Fig.  44. — Wardrop's  operation  (Holmes). 

ment.  When  moist  gangrene  follows  ligation,  amputate 
early,  above  the  ligature.  When  dry  gangrene  takes  place, 
await  a  line  of  demarcation.  Rupture  of  the  sac  after  liga- 
tion may  produce  gangrene  or  suppuration,  the  first  condition 
demanding  amputation,  and  the  second  incision  for  drainage. 
Injection  of  agents  to  produce  coagulation  (ergot,  per- 
chlorid  of  iron,  etc.)  is  very  dangerous  and  is  to  be  utterly 
condemned.  It  may  lead  to  suppuration,  gangrene,  rupture, 
or  embolism.  Manipulation  to  break  up  the  clot  was  sug- 
gested by  Sir  Wm.  Fergusson,  and  has  been  practised.  The 
object  aimed  at  is  to  have  a  fragment  of  clot  block  up  the 
vessel  upon  the  peripheral  side  of  the  artery  and  act  like  a 
distal  ligature.  The  method  is  dangerous  and  should  never 
be  employed. 

Amputation  for  aneurysm  is  performed  in  some  perilous 
cases  of  subclavian  aneurysm,  instead  of  distal  ligation. 

Electrolysis. — An  attempt  may  be  made  to  coagulate  the 
blood  at  once,  or  from  time  to  time  an  endeavor  may  be  made 
to  produce  fibrinous  deposits,  but  the  first  method  is  the 
better.     It  is,  however,  rarely  possible  to  at    once  occlude 


DISEASES  AND    IXJURIES   OF  HEART  AND    VESSELS.     255 

a  sac,  and  pulsation,  which  is  for  a  time  aboHshed,  recurs 
as  the  gas  present  is  absorbed.  Use  the  constant  current. 
Take  from  three  to  six  cells  which  stand  in  point  of  size 
between  those  used  for  cautery  and  those  used  for  ordinary 
medical  purposes.  A  platinum  needle  is  attached  to  the 
positive  pole  and  a  steel  needle  to  the  negative  pole,  both 
needles  being  insulated  by  vulcanite  at  the  points  where  the 
skin  will  touch  them.  The  asepticized  needle  are  plunged 
into  the  sac  where  it  is  thick  and  they  are  kept  near  together. 
The  current  is  passed  for  a  variable  period  (from  half  an  hour 
to  an  hour  and  a  half).  This  operation  is  not  dangerous. 
Pressure  stops  the  bleeding.  Electrolysis  often  ameliorates, 
and  sometimes  cures,  aortic  aneur>^sms.^ 

Acupressure  consists  of  the  partial  introduction  of  a  num- 
ber of  ordinary  sewing-needles  into  an  aneur>'smal  sac  and 
leaving  them  in  it  for  five  or  six  days  or  more. 

Introduction  of  Wire. — Insert  into  the  sac  a  hypodermatic 
or  small  aspirating-needle,  and  push  through  the  needle  or 
cannula  a  considerable  quantity  of  aseptic  gold  wire,  which 
is  allowed  to  remain  permanently.  Loreta  combines  elec- 
trolysis with  the  introduction  of  wire.  Cases  have  been 
benefited,  and  several  have  been  apparently  cured  by  this 
method. 

Traumatic  aneurysm  is  a  condition  in  which,  after  punc- 
ture or  rupture  of  an  artery,  a  sac  has  formed  of  tissue  and 
if  any  wound  previously  existed,  it  has  healed.  The  treat- 
ment consists  in  ligation  by  the  method  of  Antyllus,  or  com- 
plete excision.  When  an  artery  ruptures  and  a  large  mass 
of  blood  is  extravasated  no  sac  exists,  and  it  is  an  error  to 
designate  this  condition  as  a  diffuse  traumatic  aneurj^sm.  In 
this  condition  a  large,  oblong,  fluctuating  swelling  is  found. 
If  the  rent  is  large,  there  are  bruit  and  pulsation.  There  is 
no  pulsation  in  the  arteries  below  the  aneurysm,  and  the 
limb  is  cold  and  swollen.  The  skin  is  at  first  of  a  natural 
color,  but  becomes  thin  and  purple.  If  the  main  vein  is  also 
ruptured,  or  if  the  rupture  has  occurred  into  a  large  joint, 
amputate  ;  otherwise  perform  the  operation  of  Antyllus. 

Arteriovenous  aneurysm  is  an  unnatural  passage-way 
between  a  vein  and  an  arter}',  through  which  passage  blood  cir- 
culates. There  are  two  forms  :  {a)  aneurysmal  varix,  or  Pott's 
aneurysm,  where  a  vein  and  an  artery  directly  communicate  ; 
and  [b]  varicose  aneurysm,  where  vein  and  artery  communicate 
through  an  intervening  sac.  These  conditions  arise  usually 
from  punctured  wounds,  the  instrument  passing  through  one 

^  See  John  Duncan,  in  Heath's  Dictionary . 


256 


MODERN  SURGERY. 


vessel  and  into  the  other,  blood  flowing  into  the  vein,  the 
subsequent  inflammation  gluing  the  two  vessels  together, 
and  the  aperture  failing  to  close  (aneurysmal  varix,  Fig.  45). 
After  the  infliction  of  the  wound  the  two  vessels  may  sepa- 
rate ;  the  blood  still  flows  from  artery  into  vein,  and  the 
blood-pressure,  by  consolidating  tissue,  forms  a  sac  of 
junction  (varicose  aneurysm.  Fig.  46).  Aneurysmal  varix 
is  a  far  less  grave  disorder  than  varicose  aneurysm. 

Symptoms. — In  aneurysmal  varix  a  swelling  exists  with 
the  characteristic  pulsation,  and  a  loud  whirring  bruit  is 
transmitted  along  the  veins.  The  veins  above  and  below 
the  tumor  are  enlarged,  tortuous,  and  pulsating.  A  distinct 
thrill  is  felt.  Pressure  over  the  tumor  stops  the  thrill  and 
greatly  lessens  the  bruit.  The  extremity  is  apt  to  be  swollen 
and  the  parts  are  usually  painful.  When  pressure  on  the 
main  artery  causes  the  entire   disappearance  of  the  tumor, 


Fig.  45. — Plan  of  an  aneurysmal  varix. 


Fig.  46. — Varicose  aneurysm  (Spence 


the  case  is  one  of  aneurysmal  varix ;  but  if  on  applying  this 
pressure  the  veins  collapse  and  a  distinct  tumor  remains 
which  may  be  emptied  by  direct  pressure,  the  case  is  one  of 
varicose  aneurysm.  If  light  pressure  on  one  spot  stops  both 
murmur  and  thrill,  it  is  aneurysmal  varix.  The  diagnosis 
between  the  two  is  often  impossible. 

Treatment. — Aneurysmal  varix  often  requires  only  palli- 
ative measures,  as  it  does  not  tend  to  rupture,  the  veins 
becoming  thick  and  resistant  and  after  a  time  ceasing  to 
enlarge.  Some  form  of  support  is  used.  If  the  part  is 
painful  or  the  vein  is  in  danger  of  rupture,  tie  the  artery 
above  and  below  the  opening,  or  excise  both  vessels  for 
som.e  little  distance  each  side  of  the  point  of  trouble.  Vari- 
cose aneurysm  requires  the  use  of  the  plans  ordinarily 
adopted  in  treating  aneurysm  (compression,  etc.).  If  these 
fail,  tie  the  artery  above  and  below  the  opening  without 
opening  the  sac,  or  excise  the  involved  areas  of  vein,  artery, 
and  sac. 

Cirsoid  aneurysm,  or  aneurysm  by  anastomosis, 
consists  in  great  dilatation  with  pouching  and  lengthening  of 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     257 

one  or  several  arteries.  The  disease  progresses  and  after  a 
time  involves  the  veins  and  capillaries.  The  walls  of  the  arte- 
ries thin  and  the  vessels  tend  to  rupture.  Cirsoid  aneurysm 
is  met  with  upon  the  forehead  and  scalp  of  young  people, 
where  it  sometimes  takes   origin  from   a  nevus. 

Symptoms. — A  pulsating  mass,  irregular  in  outline,  com- 
posed of  dilated,  elongated,  and  tortuous  vessels  that  empty 
into  one  another.  The  mass  is  soft,  can  be  much  reduced  by 
direct  pressure,  and  is  diminished  by  compression  of  the  main 
artery  of  supply.  A  thrill  and  a  bruit  exist.  Pregnancy 
and   puberty  cause  rapid  growth  of  a  cirsoid  aneurysm. 

Treatment. — In  treating  a  cirsoid  aneurysm  the  ligation 
of  the  larger  arteries  of  supply  is  a  wretched  failure.  Sub- 
cutaneous ligation  at  many  points  of  the  diseased  area  has 
effected  a  cure  in  some  cases,  but  it  has  failed  in  most.  Direct 
pressure  is  also  entirely  useless.  Ligation  in  mass  has  been 
successful.  Destruction  by  caustic  has  its  advocates.  Electro- 
puncture  with  circular  compression  of  the  arteries  of  supply 
has  once  or  twice  effected  a  cure.  Injection  of  astringents 
has  been  recommended.  Verneuil  ligated  the  afferent  ar- 
teries, incised  the  tissues  around  the  tumor,  and  sunk  a 
constricting  ligature  into  the  cut.  The  proper  method  of 
treatment  is  excision  after  subcutaneous  ligation  of  every 
accessible  tributary  of  supply.' 

Wounds  of  arteries  are  divided  into  contused,  incised, 
lacerated,  punctured,  and  gunshot  wounds,  and  vascular 
ruptures. 

Contused  and  Incised  Wounds. — A  contusion  may  de- 
stroy vitality  and  be  followed  by  sloughing  and  hemorrhage. 
A  contused  wound  may  do  little  damage,  or  it  may  produce 
gangrene  from  thrombus,  or  it  may  cause  secondary  hemor- 
rhage. In  an  incised  wound  there  is  profuse  hemorrhage. 
The  artery  after  a  time  is  apt  to  contract  and  retract,  and 
thus  arrest  bleeding.  A  transverse  wound  causes  profuse 
bleeding,  but  there  is  a  better  chance  for  natural  arrest  than 
in  an  oblique  or  in  a  longitudinal  wound.  In  a  partially 
divided  artery,  cut  it  entirely  through  and  tie  both  ends. 
The  clot  which  forms  in  a  cut  artery  is  known  as  the  "  in- 
ternal clot ;"  it  reaches  as  high  as  the  first  collateral  branch, 
and  subsequently  becomes  organized  permanently,  obliter- 
ates the  vessel,  and  converts  it  into  a  shrunken  fibrous  cord. 
Between  the  vessel  and  its  sheath,  over  the  end  of  the  vessel, 
and  in  the  surrounding  perivascular  tissues  is  the  "  external 
clot." 

^  Anderson,  in  Heath's  Dictionary. 
17 


258  MODERN  SURGERY. 

Lacerated  -wounds  cause  little  primary  hemorrhage.  The 
internal  coat  curls  up,  the  circular  muscular  fibers  of  the 
media  contract  upon  it,  and  the  external  coat  is  so  pulled  out 
as  to  cap  the  orifice  of  the  vessel — all  of  which  conditions 
favor  clotting.  The  vessel-wall  is  so  damaged  that  secondary 
hemorrhage  is  usual. 

Punctured  "Wounds. — In  punctured  wounds  primary  hem- 
orrhage is  slight.  Secondary  hemorrhage  is  not  usual.  Dif- 
fuse aneurysm  and  arteriovenous  aneurysm  are  not  unusual 
results. 

Gunshot-^wounds  are  apt  to  be  contusions  which  may 
eventuate  in  sloughing  and  secondary  hemorrhage  or  throm- 
bosis and  gangrene.  A  shell-fragment  makes  a  lacerated 
wound.  A  modern  rifle-bullet  makes  a  clean-cut  division 
of  an  artery.  Secondary  hemorrhage  after  gunshot-wounds 
tends  to  occur  during  the  third  week.  Partial  rupture  of  an 
artery  may  cause  sloughing  and  secondary  hemorrhage, 
thrombosis  and  gangrene,  and  aneurysm.  Complete  rupture 
is  a  lacerated  wound,  and  is  a  condition  accompanied  by  dif- 
fuse traumatic  aneurysm. 

"Wounds  of  veins  are  classified  as  are  wounds  of  arteries. 
The  symptom  of  any  vascular  wound  is  hemorrhage. 

I.   Hemorrhage,  or  Loss  of  Blood. 

HemoiTliage  may  arise  from  wounds  of  arteries,  veins,  or 
capillaries,  or  from  wounds  of  the  three  combined.  In  arte- 
rial hemorrhage  the  blood  is  scarlet  and  appears  in  jets  from 
the  proximal  end  of  the  vessel,  which  jets  are  synchronous 
with  the  pulse-beats ;  the  stream,  however,  never  intermits. 
The  stream  from  the  distal  end  is  darker  and  is  not  pulsatile. 
Venous  hemorrhage  is  denoted  by  the  dark  hue  of  the  blood 
and  by  the  continuous  stream.  In  capillary  hemorrhage  red 
blood  wells  up  like  water  from  a  sponge. 

In  subcutaneous  hemorrhage  from  vascular  rupture  (diffuse 
aneurysm)  there  are  great  swelling,  cutaneous  discoloration, 
and  systemic  signs  of  hemorrhage.  If  a  main  artery  ruptures 
in  an  extremity,  there  is  no  pulse  below  the  rupture,  and  the 
limb  becomes  cold  and  swollen.  At  the  seat  of  rupture  a 
large  fluctuating  swelling  forms,  and  sometimes  there  is  bruit 
and  pulsation.  If  a  vein  ruptures  in  an  extremity,  intense 
edema  occurs.  Profuse  hemorrhage  induces  constitutional 
symptoms,  and  death  may  occur  in  a  few  seconds.  Loss  of 
half  of  the  blood  will  usually  cause  death  (from  four  to  six 
pounds),  though  women  can  stand  the  loss  of  a  greater  rela- 


DISEASES  AND   INJURES   OF  HEART  AND    VESSELS.     259 

tive  proportion  of  blood  than  men.  Generally,  after  the  bleed- 
ing has  gone  on  for  a  time  syncope  occurs,  which  is  Nature's 
effort  to  arrest  hemorrhage,  for  during  this  state  the  feeble  cir- 
culation and  the  increased  coagulability  of  blood  give  time  for 
the  formation  of  an  external  clot.  When  reaction  occurs  the 
clot  may  hold  and  be  reinforced  by  an  internal  clot,  or  it  may 
be  washed  away  with  a  renewal  of  bleeding  and  syncope.  These 
episodes  may  be  repeated  until  death  supervenes.  Nausea 
and  vertigo  are  present,  black  specks  float  before  the  eyes 
(muscae  volitantes),  tinnitus  aurium  exists.  The  patient  is 
restless  and  tosses  to  and  fro,  and  great  thirst  is  complained 
of  Delirium  is  not  unusual,  and  convulsions  often  occur. 
After  a  profuse  hemorrhage  an  individual  is  intensely  pale 
and  his  skin  has  a  greenish  tinge  ;  the  eyes  are  fixed  in  a  glassy 
stare  and  the  pupils  are  widely  dilated ;  the  respirations  are 
shallow  and  sighing ;  the  skin  is  covered  with  a  cold  sweat ; 
the  legs  and  arms  are  extremely  cold  ;  the  pulse  is  soft,  small, 
compressible,  fluttering,  or  often  cannot  be  detected ;  the 
heart  is  very  weak  and  fluttering;  there  is  muscular  tremor; 
the  patient  tosses  about,  and  asks  often  for  water.  In  hem- 
orrhage the  hemoglobin  is  greatly  diminished  in  amount. 
When  such  a  dangerous  condition  is  due  to  a  visible  hem- 
orrhage, temporarily  arrest  bleeding  by  digital  pressure  in 
the  wound,  or  the  application  of  an  Esmarch  band  above  the 
wound  (if  the  bleeding  is  arterial).  In  some  cases  forced 
flexion  is  used.  Lower  the  head,  and  have  compression 
made  upon  the  femorals  and  subclavians,  so  as  to  divert 
more  blood  to  the  brain.  Apply  artificial  heat.  Inject  by 
hypodermoclysis  the  normal  salt  solution  (10  to  16  ounces) 
into  the  cellular  tissue  of  the  buttock,  or  transfuse  the  salt  so- 
lution into  a  vein,  inject  ether  hypodermatically,  then  brandy, 
and  then  strychnin  in  doses  of  gr.  2^.  Atropin,  digitalis,  and 
morphin  are  recommended.  Give  enemata  of  hot  coffee  and 
brandy.  Apply  mustard  over  the  heart  and  spine.  Lay  a 
hot-water  bag  over  the  heart.  As  soon  as  reaction  is  estab- 
lished, arrest  the  bleeding  permanently  by  the  ligature. 

A  severe  hemorrhage  is  apt  to  be  followed  by  fever — hem- 
orrhagic fever — due  to  the  absorption  of  fibrin  ferment  from 
extravasated  blood  and  its  action  upon  a  profoundly  debil- 
itated system.  In  this  form  of  fever  there  are  most  intense 
thirst,  violent  headache,  dimness  of  vision,  great  restlessness, 
often  mental  wandering,  with  a  very  frequent,  weak,  and  flut- 
tering heart.  After  a  severe  hemorrhage  leukocytes  are 
increased,  not  only  relatively  but  absolutely.  Red  corpuscles 
are  diminished  both  relatively  and  absolutely.     Hemoglobin 


260  MODERN  SURGERY. 

diminishes ;  many  of  the  corpuscles  become  irregular  and 
microcytes  are  noticed. 

In  treating  a  patient  who  has  reacted  after  a  severe  hem- 
orrhage, apply  cold  to  the  head  to  prevent  serous  effusion 
into  the  brain.  Aconite,  morphin,  and  neutral  mixture  are 
given  by  the  mouth.  Fluids  and  ice  are  grateful.  Fre- 
quently sponge  the  skin  with  alcohol  and  water  (S.  W.  Gross). 
Milk  punch,  koumiss,  and  beef-peptonoids  are  given  at  fre- 
quent intervals.  If  the  hemorrhage  is-  from  a  spot  inacces- 
sible to  ligation,  such  as  the  lung,  give  the  patient  3  grains  of 
gallic  acid,  i  grain  of  powdered  digitalis,  i  grain  of  ergotin, 
and  \  grain  of  powdered  opium  every  three  or  four  hours. 

Hemostatic  agents  comprise  (i)  the  ligature;  (2)  torsion; 
(3)  acupressure  ;  (4)  elevation  ;  (5)  compression  ;  (6)  styptics  ; 
(7)  the  actual  cautery ;  and  (8)  forced  flexion  of  hmbs. 

The  ligature  may  be  made  of  silk,  floss-silk,  or  catgut,  but 
it  must  be  aseptic.  The  Hgatures  should  be  about  ten  inches 
long.  The  vessel  is  drawn  out  with  forceps  and  separated 
from  surrounding  tissues.  The  forceps  are  better  than  the 
tenaculum  in  most  cases,  because  the  tenaculum  makes  a  hole 
through  which  blood  may  subsequently  exude.  When  the  ar- 
tery lies  in  hard  tissues  or  is  retracted  deeply  in  muscle  or  fascia, 
the  tenaculum  is  best.  Tie  with  a  reef-knot.  The  tightening 
of  the  first  knot  cuts  the  internal  and  middle  coats.  The 
second  knot  must  not  be  tied  too  tightly,  or  it  will  cut  the  lig- 
ature. Do  not  jerk  the  ligature  in  tying,  and  cut  off  closely. 
Both  ends  of  the  vessel  are  tied.  If  an  artery  is  incompletely 
divided,  tie  on  each  side  of  the  cut  and  entirely  sever  the  ves- 
sel between  the  ligatures.  If  a  large  vein  is  slightly  torn,  try 
pinching  up  the  vein-walls  around  the  rent  and  apply  a  liga- 
ture (lateral  hgature)  (Fig.  48).  If  a  vein  is  longitudinally  torn, 
sew  up  with  a  Lembert  suture  of  silk  (Ricard  and  Niebergall 
have  done  this  successfully).  In  extensive  tears  tie  both  ends 
of  the  vein  ;  cut  the  vein  between  the  ligatures.  If  the  bleeding 
comes  from  an  artery  very  close  to  its  point  of  origin,  tie  the 
main  trunk  as  well  as  the  bleeding  branch,  otherwise  the  clot 
formed  will  be  too  short  and  secondary  hemorrhage  will  be 
inevitable.  When  the  parts  about  an  artery  are  so  thickened 
that  the  artery  cannot  be  drawn  out,  arm  a  Hagedorn  needle 
(Fig.  47)  with  catgut  and  so  pass  the  latter  around  the  vessel 
that  the  catgut  will  include  the  vessel  with  some  of  the  sur- 
rounding tissue,  and  tie  the  ligature.  This  method  is  pursued 
in  necrosis,  atheroma,  scar-tissue,  sloughing,  etc.  Never  in- 
clude a  nerve.  If  this  mode  of  ligation  fails,  try  acupressure. 
Murphy  of  Chicago  has  recently  shown  that  longitudinal 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     26 1 

wounds  or  small  lateral  wounds  of  either  veins  or  arteries 
can  be  closed  successfully  with  silk  sutures,  and  if  a  trans- 
verse wound  includes  more  than  one-third  of  the  circum- 


FiG.  47. — Hagedorn  needles. 


Fig.  48. — Method  of  controlling  hemorrhage  by  liga- 
ture (after  Esmarch)  :  a,  artery  ligated ;  b,  lateral 
ligature  of  vein. 


ference  of  the  vessel,  after  the  vessel  is  completely  divided 
the  ends  can  be  successfully  united.^ 

Torsion. — By  means  of  torsion  the  internal  and  middle 
coats  are  ruptured  and  the  external  coat  is  twisted.  It  is  a 
safe  procedure,  and  is  practised  upon  vessels  as  large  as  the 
femoral  by  many  surgeons  of  high  standing.     Torsion  has 


Fig.  49. — Method  of  controlling  hemorrhage  by  torsion. 

the  signal  merit  of  not  introducing  possible  infection  in  liga- 
tures. The  vessel  is  drawn  out  by  one  pair  of  forceps,  and 
another  pair  is  applied  transversely  half  an  inch  above  the 
cut  end  and  twisted  six  or  eight  times  (Fig.  49). 

1  See  Med.  Record.,  Jan.  16,  1897. 


262  MODERN  SURGERY.     . 

Acupressure  is  pressure  with  a  pin.  The  arrest  of  hemor- 
rhage by  acupressure  was  devised  by  Sir  James  Y.  Simpson. 
A  pin  is  simply  passed  under  a  vessel  (transfixion),  leaving  a 
little  tissue  on  each  side  between  the  pin  and  vessel.  A 
needle  can  be  passed  under  a  vessel,  and  a  wire  be  thrown 
over  the  needle  and  twisted  (circumclusion).  The  needle 
can  be  inserted  upon  one  side,  passed  through  half  an  inch 
of  tissues  up  to  the  vessel,  be  given  a  quarter-twist,  and  be 
driven  into  the  tissues  across  the  artery  (torsoclusion).  Some 
tissue  is  picked  up  on  the  needle,  folded  over  the  vessel,  and 
pinned  to  the  other  side  (retroclusion).  Acupressure  is  used 
for  inflamed  or  atheromatous  vessels,  in  sloughing  wounds, 
and  where  a  ligature  will  not  hold. 

Elevation  is  used  as  a  temporary  expedient  or  as  an  asso- 
ciate of  some  other  method.  It  is  of  use  in  wounds  of  the 
bursae,  in  bleeding  from  a  ruptured  varicose  vein,  and  is  fre- 
quently used  with  compression. 

Compression  is  either  direct  or  indirect — that  is,  in  the 
wound  or  upon  its  artery  of  supply.  In  the  removal  of  the 
upper  jaw  arrest  bleeding  by  plugging.  In  injury  of  a  cere- 
bral sinus,  plug  with  gauze.  Compression  and  hot  water 
(120°)  will  stop  capillary  bleeding.  A  graduated  compress 
is  often  used  in  hemorrhage  from  the  palmar  arch.  A  com- 
press will  arrest  bleeding  from  superficial  veins.  The  knotted 
bandage  of  the  scalp  will  arrest  bleeding  from  the  temporal 
artery.  Long-continued  pressure  causes  pain  and  inflam- 
mation. 

Styptics. — Chemicals  are  now  rarely  used.  In  epistaxis 
we  may  pack  with  plugs  of  gauze  saturated  in  antipyrin. 
In  bleeding  from  a  tooth-socket  freeze  with  chlorid  of  ethyl 
spray,  and  then  pack  with  gauze  soaked  in  10  per  cent,  solu- 
tion of  antipyrin  or  with  styptic  cotton  (absorbent  cotton 
soaked  in  Monsel's  solution  and  dried).  In  bleeding  from 
an  incised  urinary  meatus  pack  with  styptic  cotton.  Cold 
water,  chlorid  of  ethyl  spray,  or  ice  acts  as  a  styptic  by  pro- 
ducing reflex  vascular  contraction.  Hot  water  produces 
contraction  and  coagulates  the  albumin.  The  temperature 
should  be  from  115°  to  I2Q°  F.  A  mixture  of  equal  parts 
of  alcohol  and  water  stops  capillary  oozing.  Paul  Carnot 
has  recently  shown  that  a  solution  of  gelatin  in  normal  salt 
solution  (i  :  16)  will  arrest  capillary  oozing  even  in  a  hemo- 
philiac. We  have  recently  employed  this  mixture  with  satis- 
factory results  for  capillary  oozing  from  an  incised  wound  in 
a  victim  of  leukemia,  and  for  the  arrest  of  epistaxis. 

Tlie  actual  cauteiy  is  a  most  ancient  hemostatic.      It  is 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     263 

still  used  in  some  cases  after  excising  the  upper  jaw,  in 
bleeding  after  the  removal  of  some  malignant  growths,  in 
continued  hemorrhage  from  the  prostatic  plexus  of  veins, 
after  lateral  lithotomy,  and  to  stop  oozing  after  the  excision 
of  venereal  warts.  We  are  driven  to  it  in  "  bleeders  " — that 
is,  those  persons  who  have  a  hemorrhagic  diathesis,  and  who 
may  die  from  having  a  tooth  pulled  or  from  receiving  a 
scratch.  It  will  arrest  hemorrhage,  but  sloughing  is  bound 
to  occur,  and  when  the  slough  separates  secondary  hemor- 
rhage is  apt  to  set  in.  The  iron  for  hemostatic  purposes 
must  be  at  a  black  heat. 

Forced  flexion  is  a  variety  of  indirect  compression  intro- 
duced by  Adelmann.  It  will  stop  bleeding,  but  soon  be- 
comes intensely  painful.  Forced  flexion  can  be  maintained 
by  bandages.  Brachial  hyperflexion  is  maintained  by  tying 
the  forearm  to  the  arm.  It  is  often  associated  with  the  use 
of  a  pad  in  front  of  the  elbow.  Genuflexion  is  kept  up  by 
tying  the  foot  to  the  thigh.  It  is  increased  in  efficiency  by 
placing  a  pad  in  the  popliteal  space. 

Golden  Rides  for  Procedure  in  Primary  Hemorrhage. — 
I.  In  arterial  hemorrhage  tie  the  artery  in  the  wound, 
enlarging  the  wound  if  necessary.  In  tying  the  main  artery 
of  the  limb  in  continuity  for  bleeding  from  a  point  below  we 
fail  to  cut  off  the  bleeding  from  the  distal  extremity,  and 
hemorrhage  is  bound  to  recur.  If  we  fail  to  look  into  the 
wound,  we  cannot  know  what  is  cut :  it  may  be  only  a 
branch,  and  not  a  main  trunk.  The  same  rule  obtains  in 
secondary  hemorrhage  (Guthrie's  rule).^ 

2.  We  can  safely  ligate  veins  as  we  would  arteries. 

3.  In  a  wound  of  the  superficial  palmar  arch  tie  both  ends 
of  the  divided  vessel. 

4.  In  a  wound  of  the  deep  palmar  arch  enlarge  the 
wound,  if  necessary,  in  the  direction  of  the  flexor  tendons,  at 
the  same  time  maintaining  pressure  upon  the  brachial  artery. 
Catch  the  ends  of  the  arch  with  hemostatic  forceps  and  tie 
both  ends.  If  the  artery  can  be  caught  by,  but  cannot  be 
tied  over  the  point  of,  the  forceps,  leave  the  instrument  on 
for  four  days.  If  the  artery  cannot  be  caught  with  forceps, 
try  a  tenaculum.  If  these  means  fail,  insert  a  small  piece  of 
gauze  in  the  depth  of  the  wound,  put  over  this  a  larger  piece, 
and  keep  on  adding  bit  after  bit,  each  one  larger  than  its 
predecessor,  until  there  is  constructed  a  conical  pad  the 
apex  of  which  is  against  the  extremities  of  the  cut  arch  and 
the  base  of  which  is  well  external  to  the  palm.     Bandage 

^  For  Murphy's  observations  on  anastomosis  of  vessels,  see  page  2^1. 


264  MODERN  SURGERY. 

each  finger  and  the  thumb,  put  a  piece  of  metal  over  the 
pad,  wrap  the  hand  in  gauze,  place  the  arm  upon  a  straight 
splint,  apply  firmly  an  ascending  spiral  reverse  bandage  of 
the  arm.  starting  as  a  figure-of-8  of  the  wrist,  and  hang  the 
hand  in  a  sling.  Instead  of  applying  a  splint,  we  may  place 
a  pad  in  front  of  the  elbow  and  flex  the  forearm  on  the  arm. 
The  palmar  pad  is  left  in  place  for  six  or  seven  days  unless 
bleeding  keeps  on  or  recurs.  If  bleeding  is  maintained  or 
begins  again,  ligate  the  radial  and  ulnar.  If  this  maneuver 
fails,  we  know  that  the  interosseous  arter}'  is  furnishing  the 
blood  and  that  the  brachial  must  be  tied  at  the  bend  of  the 
elbow.  If  this  fails,  amputate  the  hand.  A  plan  which  might 
obviate  these  radical  procedures  is  to  incise  on  a  line  with 
the  injur}-  from  the  web  of  the  fingers  to  above  the  carpus, 
separating  the  metacarpal  and  carpal  bones  until  the  arten,' 
is  exposed  (this  is  really  Mynter's  incision  for  excision  of 
the  wrist). 

5.  In  primar}-  hemorrhage,  if  the  bleeding  ceases,  do  not 
disturb  the  parts  to  look  for  the  vessel.  If  the  vessel  is 
clearly  seen  in  the  wound,  tie  it ;  otherwise  do  not,  as  the 
bleeding  may  not  recur.  This  rule  does  not  hold  good 
when  a  large  artery  is  probably  cut,  when  the  subject  will 
require  transportation  (as  on  the  battle-field),  when  a  man 
has  delirium  tremens,  mania,  or  delirium,  or  when  he  is  a 
hea\y  drinker.  In  these  cases  always  look  for  an  arter}' 
and  tie  it. 

6.  When  a  person  is  bleeding  to  death,  arrest  hemorrhage 
temporarily  by  digital  pressure  in  the  wound  and  apply 
above  the  wound  a  tourniquet  or  Esmarch  bandage.  Bring 
about  reaction  and  then  ligate,  but  do  not  operate  during 
collapse  if  the  bleeding  can  be  controlled  by  pressure. 

7.  If  a  transverse  cut  incompletely  divides  an  artery,  it 
may  be  found  possible  to  suture  the  cut  if  it  does  not  in- 
clude more  than  one-third  of  the  circumference  of  the  ves- 
sel. Longitudinal  cuts  can  be  sutured  (Murphy).  If  sutur- 
ing is  impossible,  or  if  the  surgeon  prefers  not  to  attempt  it, 
apply  a  ligature  on  each  side  of  the  vessel-wound  and  then 
sever  the  arter\-  so  as  to  permit  of  complete  retraction. 

8.  If  a  branch  comes  oiT  just  below  the  ligature,  tie  the 
branch  as  well  as  the  main  trunk. 

9.  If  a  branch  of  an  arter)'  is  divided  ver>'  close  to  a  main 
trunk,  tie  the  branch  and  also  the  main  trunk.  If  the 
branch  alone  be  tied,  the  internal  clot,  being  ver}^  short,  will 
be  washed  away  by  the  blood-current  of  the  larger  vessel. 

10.  If  a  large  vein  is  shghtly  torn,  put  a  lateral  hgature 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     265 

upon  its  wall.  Gather  the  rent  and  the  tissue  around  it  in  a 
forceps  and  tie  the  pursed-up  mass  of  vein-wall.  It  is  a  wise 
plan  to  pass  the  suture  through  the  two  outer  coats  by^  means 
of  a  needle  and  tie  the  knot  subsequently.     This  expedient 


Fig.  50. — Application  of  lateral  ligature  to  a  vein. 

prevents  slipping.  If  a  longitudinal  wound  exists  in  a  large 
vein,  take  an  intestinal  needle  and  fine  silk  and  sew  it  up 
with  a  Lembert  suture. 

1 1.  When  a  branch  of  a  large  vein  is  torn  close  to  the 
main  trunk,  tie  the  branch,  and  not  the  main  trunk.  Apply 
practically  a  lateral  ligature. 

1 2.  If,  after  tying  the  cardial  extremity  of  a  cut  arter}',  the 
distal  extremity  cannot  be  found  even  by  a  careful  search 
after  enlarging  the  wound,  firmly  pack. 

13.  In  bleeding  from  diploe  or  cancellous  bone,  use  Hors- 
ley's  antiseptic  wax  or  break  in  bony  septa  with  a  chisel. 

14.  In  bleeding  from  a  vessel  in  a  bony  canal,  plug  the 
canal  with  an  antiseptic  stick  and  break  the  wood,  or  fill  up 
the  orifice  of  the  canal  with  antiseptic  wax ;  or,  if  this  fails, 
ligate  the  arter}^  of  supply. 

15.  In  bleeding  from  the  internal  mammar\'  artery  the  old 
rule  was  to  pass  a  large  curved  needle  holding  a  piece  of 
silk  into  the  chest,  under  the  vessel  and  out  again,  and  tie 
the  thread  tightly,  but  it  is  better  to  ligate  the  artery. 

16.  In  bleeding  from  an  intercostal  artery  make  pressure 
upward  and  outward,  or  throw  a  ligature  by  means  of  a 
curved  needle  entirely  over  a  rib,  tying  it  externally,  or, 
what  is  better,  resect  a  rib  and  tie  the   artery. 

17.  In  collapse  due  to  puncture  of  a  deep  vessel,  the  bleed- 
ing having  ceased,  do  not  hurry  reaction  by  stimulants.  Give 
the  clot  a  chance  to  hold.  Wrap  the  sufferer  in  hot  blankets. 
If  the  condition  is  dangerous,  however,  stimulate  to  save  life. 

18.  In  punctured  wounds,  as  a  rule,  try  pressure  before 
using"  lisration. 


266  MODERN  SURGERY. 

19.  After  a  severe  hemorrhage  always  put  the  patient  to 
bed  and  elevate  the  damaged  part  (if  it  be  an  extremity  or 
the  head). 

20.  A  clot  which  holds  for  twelve  hours  after  a  primary- 
hemorrhage  will  probably  hold  permanently ;  but  even  after 
twelve  hours  be  watchful  and  insist  on  rest. 

21.  If  recurrence  of  a  hemorrhage  from  a  limb  is  feared, 
mark  with  anilin  or  iodin  the  spot  on  the  main  artery  where 
compression  is  to  be  applied,  put  on  a  tourniquet  loosely,  and 
order  the  nurse  to  screw  it  up  and  to  send  for  the  physician 
at  the  first  sign  of  renewed  bleeding.  This  must  often  be 
done  in  gunshot-wounds. 

22.  When  the  femoral  vein  is  divided  high  up  the  advice 
commonly  given  is  to  ligate  the  vein  and  also  the  femoral 
artery.  Branne  taught  that  because  of  the  venous  valves 
there  is  no  collateral  circulation,  and  to  tie  the  vein  alone 
renders  gangrene  inevitable.  Niebergall  shows  that  the 
valves  may  be  overcome  by  moderate  arterial  pressure,  and 
thus  collateral  circulation  is  established.  Hence,  when  the 
femoral  vein  is  divided  tie  the  vein,  but  leave  the  artery  un- 
tied, so  as  to  furnish  the  necessary  pressure.^ 

23.  In  extradural  hemorrhage  trephine.  The  side  to  be 
trephined  is  determined  by  the  symptoms,  and  not  by  the 
situation  of  the  injury.  The  opening  is  made  on  a  level  with 
the  upper  orbital  border  and  one  and  a  quarter  inches  be- 
hind the  external  angular  process.  This  opening  exposes 
the  middle  meningeal  and  its  anterior  branch  (Keen).  If  this 
does  not  expose  a  clot,  trephine  over  the  posterior  branch, 
on  the  same  level  and  just  below  the  parietal  eminence. 
When  the  clot  is  found  enlarge  the  opening  with  the  ron- 
geur, scoop  out  the  clot,  and  stop  the  bleeding  by  passing 
catgut  ligatures  on  each  side  of  the  injury  in  the  vessel 
through  the  dura,  under  the  artery  and  out  again,  and  then 
tying  them.  If  the  artery  lies  in  a  bony  canal,  plug  the  canal 
with  Horsley's  wax. 

24.  In  hemorrhage  from  a  cerebral  sinus  catch  the  edges 
of  the  opening  with  forceps  if  possible  and  apply  a  lateral 
ligature,  or  leave  the  forceps  on  forty-eight  hours  or  com- 
press firmly  with  one  large  piece  of  iodoform  gauze. 

25.  In  extrameduUary  spinal  hemorrhage  rapidly  advanc- 
ing and  threatening  life  perform  a  laminectomy  and  arrest 
the  hemorrhage. 

26.  In  bleeding  from  a  tooth-socket  use  chlorid-of-ethyl 
spray  or  ice.     If  this  treatment  fails,  plug  with  gauze  infil- 

1  Niebergall,  in  Deut.  Zeit.f.  C/iir.,  vol.  xxxvii.,  Nos.  3,  4. 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     267 

trated  with  tannin  or  soaked  in  antipyrin  solution  of  a  strength 
of  10  per  cent.,  or  in  Carnot's  solution  of  gelatin,  close  the 
jaws  upon  the  plug,  and  hold  them  with  Barton's  bandage. 
If  this  expedient  fails,  soak  the  plug  in  Monsel's  solution, 
and  if  this  is  futile,  use  the  cautery.  Pressure  on  the  carotid 
and  ice  over  the  jaw  and  neck  are  indicated.  It  may  be 
necessary  to  tie  the  external  carotid  artery. 

27.  In  intra-abdominal  hemorrhage  open  the  belly.  In 
intra-abdominal  hemorrhage  it  is  necessary  to  operate  dur- 
ing shock.  If  the  blood  accumulates  so  rapidly  as  to  prevent 
the  location  of  the  bleeding  point,  compress  the  aorta  or  pack 
the  abdominal  cavity  with  large  sponges.  In  seeking  for  the 
bleeding  point  remove  the  sponges  one  by  one,  or  have  the 
pressure  momentarily  relaxed  from  time  to  time.  In  paren- 
chymatous hemorrhage  try  packing  with  iodoform  gauze. 
In  the  liver,  if  this  fails,  suture  the  torn  edge  or  use  the  cau- 
tery. Severe  wounds  of  the  spleen  demand  splenectomy. 
Wounds  of  the  kidney  may  be  sutured;  many  require  par- 
tial or  complete  nephrectomy.  Mesenteric  vessels  are  ligated 
en  masse  with  silk  (Senn).  Wounds  of  stomach  and  intes- 
tines causing  hemorrhage  require  stitching  of  their  edges. 
When  there  are  an  infinite  numbei:  of  points  of  bleeding  take 
a  number  of  sponges,  tie  a  piece  of  iodoform  gauze  firmly  to 
each  one,  pack  many  places  in  the  belly  with  the  sponges, 
bring  the  gauze  out  of  the  wound,  and  remove  the  sponges 
from  below  upward  one  at  a  time,  securing  the  bleeding 
points  as  they  come  into  view. 

28.  In  abdominal  section  for  disease  of  the  female  pelvic 
organs  bleeding  is  limited  by  the  clamp  or  by  pressure-for- 
ceps. Ligation  en  masse  is  often  practised.  Use  silk.  A 
large  mass  can  be  transfixed  and  tied  in  sections.  Bleeding 
edges  are  stitched.  Areas  of  oozing  are  treated  with  tem- 
porary pressure  and  hot  water,  or,  if  this  fails,  by  the  cautery. 
Packing  can  be  used  as  a  tamponade,  which  is  a  gauze  pouch, 
pieces  of  gauze  being  packed  into  this  pouch  after  its  inser- 
tion into  the  belly. 

29.  A  ruptured  varicose  vein  requires  a  compress,  a  band- 
age from  the  periphery  up,  and  elevation. 

30.  For  capillary  hemorrhage  use  hot  water  and  compres- 
sion, gelatin  dissolved  in  salt  solution,  or,  if  these  expedients 
fail,  the  cautery.  Understand  that  capillary  bleeding  does 
not  so  much  mean  bleeding  from  genuine  capillaries  as  it 
does  bleeding  from  arterioles  and  venules. 

31.  Pressure  above  a  wound  stops  arterial  hemorrhage,  but 
aggravates  venous  bleeding.     Pressure  below  a  wound  stops 


268 


MODERN  SURGERY. 


venous  hemorrhage,  but  increases  arterial  bleeding.    Remem- 
ber these  facts  when  applying  pressure. 

32.  In  severe  epistaxis,  or  bleeding  from  the  nose,  examine 
the  nose  by  means  of  a  head-mirror  and  a  speculum..  If  a 
little  point  of  ulceration  is  found,  touch  it  with  the  hot  iron. 
If  the  bleeding  is  a  general  ooze,  if  it  is  high  up,  or  if  the 
cautery  does  not  arrest  it,  pack  the  nares.  It  may  be  neces- 
sary to  pack  one  nostril  or  both.  Pass  a  Bellocq  cannula 
(Fig.  50)  along  the  floor  of  one  nostril  into  the  pharynx, 


Fig.  51.— Plugging  the  nares  for  epistaxis  (Guerin). 

project  the  stem  into  the  mouth,  tie  a  plug  of  lint  or  gauze 
to  the  stem,  and  withdraw  it.  Carry  out  the  same  procedure 
upon  the  other  nostril,  pull  the  strings  firmly  forward,  pack 
the  nostrils  from  before  backward,  and  tie  the  strings  around 
the  plug.  If  one  nostril  is  packed,  tie  the  string  ends  around 
the  plug.  Soaking  the  lint  or  gauze  in  antipyrin  solution  or 
gelatin  solution  is  a  good  plan.  Do  not  use  subsulphate  of 
iron,  as  it  forms  a  disgusting,  clotty,  adherent  mass.  If  a 
Bellocq  cannula  is  not  obtainable,  push  a  soft  catheter  into 
the  pharynx,  catch  it  with  a  finger,  pull  it  forward,  and  tie 
the  plug  to  it.  Remove  the  plug  in  three  or  four  days.  Pick 
out  the  front  plug  first,  hold  the  string  of  the  second  plug  in 
the  hand,  push  the  plug  back  into  the  pharynx,  catch  it  with 
forceps,  and  withdraw  plug  and  string  through  the  mouth. 
33.  In  gunshot-wounds  the  primary  hemorrhage  is  sHght 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     269 

unless  a  large  vessel  is  cut.  The  bleeding  may  be  visible  or 
may  be  internal  (concealed),  the  blood  running  into  a  natu- 
ral cavity  or  among  the  muscles.  Capillary  oozing  is  arrested 
by  very  hot  water  and  compression.  Venous  bleeding  is 
usually  arrested  by  compression.  If  a  large  vessel  is  the 
source  of  bleeding,  enlarge  the  wound  and  tie  the  vessel. 
If  the  artery  cannot  be  found  in  the  wound,  tie  the  main 
trunk. 

34.  In  prolonged  bleeding  from  a  leech-bite  tr\^  compres- 
sion over  a  plug  saturated  with  alum  or  with  tannin.  If  this 
fails,  pass  under  the  wound  a  harelip-pin  and  encircle  it 
with  a  piece  of  silk.     If  this  fails,  use  the  actual  cautery-. 

35.  In  severe  bleeding  from  the  ear  elevate  the  head,  put 
an  ice-bag  over  the  mastoid,  give  opium  and  acetate  of  lead, 
and,  if  blood  runs  into  the  mouth,  plug  the  Eustachian  tube 
with  a  piece  of  catheter. 

36.  Umbilical  hemorrhage  in  infants  requires  pressure 
over  a  plug  containing  tannin,  alum,  or  gelatin  solution.  If 
compression  fails,  pass  harelip-pins  under  the  navel  and  apply 
a  twisted  suture.     If  this  fails,  use  the  actual  cautery. 

37.  Rectal  bleeding  requires  elevation  of  the  buttocks, 
insertion  of  plugs  of  ice,  ice  to  the  anus  and  perineum, 
astringent  injections  (alum),  and  the  internal  use  of  opium 
and  acetate  of  lead.  If  these  means  fail,  plug  the  bowel 
over  a  catheter,  or  insert  and  inflate  a  Peterson  bag  or  a 
colpeurynter,  or  tampon  and  use  a  T-bandage.  If  the  bleed- 
ing persists  or  if  a  considerable  vessel  is  bleeding,  stretch 
the  sphincter,  catch  the  bowel  and  draw  it  down,  seize  the 
vessel,  and  tie  it  if  possible  ;  if  not,  leave  the  forceps  in  place. 
Failing  in  this,  the  actual  cautery  must  be  used. 

38.  Subcutaneous  hemorrhage,  if  severe,  demands  that  an 
incision  be  made  and  ligation  be  performed, 

39.  Bleeding  from  a  cut  urethral  meatus  requires  the 
insertion  of  styptic  cotton  and  the  application  of  pressure. 
Moderate  bleeding  from  the  urethra  can  usually  be  arrested 
by  a  hot  bougie,  by  hot  injections,  or  by  tying  a  condom 
over  a  catheter,  and,  after  inserting  it,  inflating  the  condom 
by  blowing  through  the  catheter  and  plugging  the  orifice 
of  the  instrument,  thus  using  pressure.  Sitting  with  the 
perineum  on  a  thickly  folded  towel  is  useful.  Ice  to  the 
perineum  does  good.  The  patient  can  lie  down,  have  a 
folded  towel  applied  to  the  perineum  and  a  crutch-handle 
pushed  upon  the  towel,  the  lower  end  of  the  crutch  being 
jammed  against  the  foot  of  the  bed.  If  a  solid  bougie  has 
been   first   introduced,  firm   pressure   can   be   made   by   this 


270 


MODERN  SURGERY. 


method.     If  these   means    are  futile,  perform   an    external 
urethrotomy  and  reach  the  bleeding  point. 

40.  Hemorrhage  from  the  prostate  requires  hot  injec- 
tions, the  introduction  of  a  large  bougie  first  dipped  in  very 
warm  water,  and  the  retention  of  a  catheter  for  two  days. 
Perineal  section  may  be  required,  or  suprapubic  cystotomy 
with  packing  which  does  not  occlude  the  ureteral  orifices. 

41.  Vesical  hemorrhage  usually  ceases  spontaneously,  in 
which  case  the  urine  must  be  drawn  off  and  the  viscus  be 
washed  out  frequently  with  a  solution  of  boric  acid  to  pre- 
vent septic  cystitis.  If  blood-clots  prevent  the  flow  of  urine, 
break  them  up  with  a  catheter  or  a  lithotrite  and  inject  vin- 
egar and  water,  a  2  per  cent,  solution  of  carbolic  acid,  or  a 
solution  of  bicarbonate  of  sodium.  Perfect  quiet  is  to  be 
maintained,  cold  acid  drinks  to  be  given,  ice-bags  to  be  put 
to  the  perineum  and  hypogastric  region,  and  opium  with 
acetate  of  lead,  ergot,  or  gallic  acid  to  be  given  by  the 
mouth.  If  the  hemorrhage  is  severe  or  persistent,  perform 
a  suprapubic  cystotomy. 

42.  In  hemorrhage  after  lateral  lithotomy,  ligate  if  pos- 
sible. If  the  vessel  can  be  caught  but  cannot  be  ligated, 
leave  the  forceps  in  place.     If  we  cannot  catch  the  vessel 

with  forceps,  try  a  tenaculum.  If 
the  tenaculum  fails,  pass  a  threaded 
curved  needle  through  the  tissues 
around  the  vessel  and  tie  the  ligature. 
Plugs  of  ice  and  injections  of  hot 
water  may  be  tried.  These  means 
failing,  pressure  is  indicated.  Take  a 
cannula,  fasten  to  it  a  chemise  (Fig. 
52),  empty  clots  from  the  bladder, 
insert  the  instrument  into  the  viscus, 
and  pack  gauze  between  the  sides  of 
the  cannula  and  the  chemise.  The 
chemise  is  bulged  out  and  pressure 
is  made.  Tie  the  cannula  by  means 
of  tapes  to  a  T-bandage.  Pressure 
is  thus  combined  with  vesical  drain- 
age. Buckstone  Brown  makes  press- 
ure by  inflating  a  rubber  bag  with  air. 
The  hot  iron  may  occasionally  be 
demanded. 

43.  Renal  bleeding  requires  ice  to 
the  loin,  tannic  acid  and  opium,  gallic  acid  and  sulphuric  acid, 
and  perfect  quiet.     If  the  bleeding  threatens  life  and  the  dis- 


FlG.  52. — Cannula  i  chemise. 


DISEASES  AND   IXJURIES   OF  HEART  AND    FESSELS.     2/1 

eased  organ  is  identified,  make  a  lumbar  incision,  and  suture 
or  perform  nephrectomy  ;  if  not  sure  which  organ  is  diseased, 
perform  an  abdominal  nephrectomy.  The  use  of  a  cysto- 
scope  will  show  from  which   ureter  blood  is  emerging. 

44.  Vaginal  hemorrhage  requires  the  ligature  or  the 
tampon. 

45.  Severe  uterine  hemorrhage  (unconnected  with  preg- 
nancy) requires  the  tampon.  Persistent  hemorrhage  due 
to  morbid  growths  may  require  removal  of  the  tubes  and 
appendages,  ligation  of  the  uterine  and  ovarian  arteries,  or 
hysterectomy. 

46.  Hematemesis,  or  bleeding  from  the  stomach,  is  treated 
by  the  swallowing  of  ice,  giving  tannic  acid  (dose,  20  or  30 
grains)  or  Monsel's  solution  (3  drops).  Never  give  tannic 
acid  and  Monsel's  solution  at  the  same  time,  as  they  mix 
and  form  ink.  Opium  is  usually  ordered.  Acetate  of  lead 
and  opium  and  gallic  acid  are  favorite  remedies,  and  ergot 
is  used  by  many.  Give  no  food  by  the  stomach.  If  life  is 
threatened  by  bleeding  from  an  ulcer,  open  the  belly  and 
excise  the  ulcer.  If  severe  hemorrhage  follows  injury,  make 
an  explorator}^  laparotomy. 

47.  In  bleeding  from  the  small  bowel  give  acetate  of  lead 
and  opium,  sulphuric  acid,  or  Monsel's  salt  in  pill  form 
(3  grains),  allow  no  food  for  a  time,  and  insist  on  liquid  diet 
for  a  considerable  period.  If  hemorrhage  threatens  life,  do 
a  celiotomy  and  find  the  cause.  If  ulcer  exists,  excise  it.  If 
violent  hemorrhage  follows  injury,  explore  to  discover  the 
cause. 

48.  In  bleeding  from  the  large  bowel,  use  styptic  injections 
(10  grains  of  alum  or  5  grains  of  bluestone  to  sj  of  water). 
If  bleeding  is  low  down,  use  small  amounts  of  the  solution  ; 
if  high  up,  large  amounts.  Do  not  use  absorbable  poisons. 
In  dangerous  cases  perform  an  exploratory  operation  to  find 
the  cause.     (For  rectal  bleeding  see  37,  p.  269.) 

49.  Hemoptysis,  or  bleeding  from  the  lung,  is  treated  by 
morphin  hypodermatically,  by  perfect  rest,  by  dry  cups  or 
ice  over  the  affected  spot  if  it  can  be  located,  and  by  gallic 
acid,  which  drug  aids  coagulation.'  Of  late  nitrite  of  amyl 
by  inhalation  has  given  good  results. 

50.  In  hemorrhage  from  wound  of  the  lung  do  not  open 

'  The  use  of  ergot  is  a  general  but  questionable  practice.  Bartholow  and 
others  hold  that  this  drug  does  harm  ;  it  contracts  all  the  arterioles,  and  hence 
more  blood  flows  from  an  area  where  there  is  damage.  Purgatives  do  good  in 
bleeding  from  the  lung  by  taking  blood  to  the  abdomen  and  lowering  blood- 
pressure. 


2/2  MODERN  SURGERY. 

the  chest  unless  life  is  threatened.  If  life  is  endangered, 
resect  several  ribs,  find  the  bleeding  point,  ligate  or  employ 
forcipressure.  A  small  cavity  may  be  packed  with  gauze. 
If  a  large  surface  is  bleeding,  fill  the  pleural  sac  with  gauze 
and  pack  more  gauze  against  the  oozing  surface.^ 

Reactionary  or  Recurrent  Hemorrliage  (called  also 
Consecutive,  Intermediate,  or  Intercurrentj. — This  form  of 
hemorrhage  comes  on  during  reaction  from  an  accident  or 
an  operation — that  is,  during  the  first  forty-eight  hours,  but 
usually  within  twelve  hours.  It  is  bleeding  from  a  vessel 
or  vessels  which  did  not  bleed  during  the  shock  which 
accompanied  operation,  but  were  overlooked  and  were  not 
tied.  It  may  be  due  to  faultily  applied  ligatures.  It  is 
favored  by  vascular  excitement  or  hypertrophied  heart. 
The  bleeding  is  not  sudden  and  severe,  but  is  a  gradual 
drop  or  trickle.  The  Esmarch  apparatus  is  not  unusually 
the  cause.  The  constricting  band  paralyzes  the  smaller 
arteries,  which  do  not  bleed  during  shock  and  do  not  con- 
tract as  shock  departs ;  hence  bleeding  comes  on  with  reac- 
tion. To  lessen  the  danger  of-the  Esmarch  apparatus  use 
a  broad  constricting  band  rather  than  a  rubber  tube.  During 
reaction  after  an  amputation,  if  slight  hemorrhage  occurs, 
elevate  the  stump  and  compress  the  flaps.  If  the  hemor- 
rhage persists  or  at  any  time  becomes  severe,  make  pressure 
on  the  main  artery  of  the  limb,  open  the  flaps,  turn  out  the 
clots,  find  the  bleeding  point,  ligate,  asepticize,  close,  and 
dress.  In  any  severe  reactionary  hemorrhage  open  the 
wound  at  once  and  ligate. 

Secondary  hemorrhage  may  occur  at  any  time  in  the 
period  between  forty-eight  hours  after  the  accident  or  opera- 
tion and  the  complete  cicatrization  of  the  wound.     Secondary 

hemorrhage    may    be    due    to 
atheroma,  to  slipping  of  a  lig- 
ature,   to    inclusion    of    nerve, 
fascia,  or  muscle  in  the  liga- 
ture, to    sloughing,  to   erysip- 
elas, to  septicemia,  to  pyemia, 
to  gangrene,  and  to  ov^eraction 
of  the  heart.     The   great   ma- 
jority   of  cases    of  secondary 
^'''•"■"fnrasutre-Hgaturf.'^''^^''      hemorrhage   are  due  to  infec- 
tion,   and    the    application    of 
modern  surgical  principles  has  rendered  secondary  bleeding  a 
rare  calamity.     If  during  an  operation  the  vessels  are  found 

1  See  author's  case,  Aitnals  of  Surgery,  Jan.,  1898. 


DISEASES  AND    INJURIES   OF  HEART  AND    VESSELS.     273 

atheromatous,  acupressure  had  best  be  used,  or  a  thread 
should  be  passed,  by  means  of  a  Hagedorn  needle,  around 
the  vessel,  including  a  cushion  of  tissue  in  the  loop  of  the 
ligature  (this  prevents  cutting  through)  (Fig.  53).  One  great 
trouble  with  atheromatous  arteries  is  that  their  coats  can- 
not contract ;  another  trouble  is  that  the  ligature  cuts  en- 
tirely through  them.  If  after  an  operation  the  pulse  is  found 
to  be  forcible,  rapid,  and  jerking,  give  aconite,  opium,  and  low 
diet.  The  bleeding  may  come  on  suddenly  and  furiously, 
but  is  usually  preceded  by  a  bloody  stain  in  wound-fluids 
which  had  become  free  from  blood. 

Treatment  of  Secondary  Hemorrhage. — The  method  of 
treatment,  supposing  a  case  of  leg-amputation  in  which,  sev- 
eral days  after  the  operation,  a  little  oozing  is  detected,  is  to 
elevate  the  stump,  apply  two  compresses  over  the  flaps,  and 
carry  a  firm  bandage  up  the  leg.  If  the  bleeding  is  profuse 
or  becomes  so,  make  pressure  on  the  main  artery,  open  and 
tear  the  flaps  apart  with  the  fingers,  find  the  bleeding  vessel 
and  tie  it,  turn  out  the  clots,  asepticize,  close,  and  dress.  If 
the  bleeding  begins  at  a  period  when  the  stump  is  nearly 
healed,  cut  down  on  the  main  artery  just  above  the  stump 
and  ligate.  In  secondary  hemorrhage  from  a  blood-vessel 
in  nodular  tissue  throw  a  ligature  around  the  vessel  by  a 
curved  needle  or  tie  higher  up,  or,  if  this  fails,  amputate. 
When  secondary  hemorrhage  arises  in  a  sloughing  wound 
apply  a  tourniquet  or  an  Esmarch  bandage,  tear  the  wound 
open  to  the  bottom  with  a  grooved  director,  look  for  the 
orifice  of  the  vessel,  dissect  the  artery  up  until  a  healthy 
point  is  reached,  cut  it  across,  and  tie  both  ends.  If  this 
fails,  include  tissue  in  the  ligature  or  use  acupressure.  In 
secondary  hemorrhage  from  atheromatous  vessels  use  acu- 
pressure or  include  surrounding  tissue  in  the  ligature. 

Secondary  hemorrhage  may  occur  after  ligation  in  con- 
tinuity, the  blood  usually  coming  from  the  distal  side.  If 
the  dressings  are  slightly  stained  with  blood,  put  on  a  gradu- 
ated compress.  If  the  bleeding  continues  or  is  severe,  make 
pressure  on  the  main  artery  of  the  limb,  open  the  wound  and 
ligate,  wrap  the  part  in  cotton,  deviate,  and  surround  with  hot 
bottles.  If  this  re-ligation  is  done  on  the  femoral  and  fails, 
do  not  ligate  higher  up,  as  gangrene  will  certainly  occur,  but 
amputate  at  once,  above  the  point  of  hemorrhage.  If  dealing 
with  the  brachial  artery,  do  not  amputate,  but  ligate  higher 
up  and  make  compression  in  the  wound.  In  a  secondary 
hemorrhage  from  the  innominate  tie  the  innominate  again 
and  also  tie  the  vertebral. 

IS 


^74  MODERN  SURGERY. 

2.  Operations  on  the  Vascular  System. 

Paracentesis  auriculi,  or  tapping  the  heart-cavity,  has 
been  suggested  for  the  rehef  of  an  over-distended  heart  from 
pulmonary  congestion.  The  right  auricle  should  be  tapped. 
Push  the  aspirator-needle  directly  backward  at  the  right  edge 
of  the  sternum,  in  the  third  interspace.  This  operation  is  not 
recommended,  as  it  is  highly  dangerous  and  is  of  question- 
able value. 

Paracentesis  pericardii,  or  tapping  the  pericardial  sac, 
is  only  done  ,when  life  is  endangered.  Introduce  the  needle 
two  inches  to  the  left  of  the  left  edge  of  the  sternum,  in  the 
fifth  interspace,  and  push  it  directly  backward  (thus  avoiding 
the  internal  mammary  artery). 

Operation  for  Varix  of  I/Cg. — In  this  operation  make, 
at  several  points  in  the  course  of  the  long  saphenous  vein, 
skin  incisions  each  two  inches  long  and  in  the  long  axis  of 
the  vessel.  Clear  the  vessel  at  each  incision,  apply  two  liga- 
tures an  inch  apart,  and  excise  the  vein  between  them.  Never 
operate  if  the  slightest  phlebitis  exists  (Barker).  This  method 
of  multiple  ligation  is  the  plan  of  Phelps.  Another  method 
is  as  follows :  the  patient  stands  for  a  time  before  a  fire  to 
enlarge  the  veins.  A  harelip-pin  is  pushed  into  the  tissues 
an  inch  from  the  vein,  at  the  upper  end  of  its  varicose  por- 
tion ;  the  pin  is  passed  under  the  vein  and  emerges  an  inch 
outside  of  it.  A  bit  of  catheter  wrapped  in  gauze  is  laid  over 
the  vein,  and  a  twisted  suture  is  carried  around  the  pin  and 
over  the  pad.  This  operation  is  done  lower  down  in  one  or 
two  positions ;  but  it  is  unsatisfactory,  and  offers  grave  dan- 
ger of  infection.  Trendelenburg,  at  a  point  below  the  saph- 
enous opening,  ties  the  vein  in  two  places  and  divides  it  be- 
tween his  ligatures.  Some  surgeons  have  advised  the  removal 
of  the  entire  length  of  the  long  saphenous  vein.  Madelung 
cuts  down  over  the  varices  and  ligates.  Schede  makes  a  cir- 
cular cut  completely  around  the  leg  at  the  junction  of  the 
upper  and  middle  thirds,  the  incision  reaching  to  the  deep 
fascia.  All  bleeding  points  are  ligated  and  the  edges  of  the 
incision  are  sewn  together.  Fergusson  ties  the  saphenous 
vein  near  the  femoral  and  removes  a  section  from  it.  This 
makes  the  varices  clearly  evident.  A  semilunar  incision  is 
made  to  surround  the  varices,  which  incision  reaches  to  the 
deep  fascia.  The  flap  is  raised  and  dissected  up,  the  vessels 
are  tied,  and  the  flap  is  sutured  in  place.  The  author  of  this 
operation  claims  that  it  is  most  satisfactory  and  certain. 

Open  Operation  for  Varicocele. — The  open  operation 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     275 

is  by  far  the  best  procedure  for  varicocele.  The  instruments 
used  are  a  scalpel,  an  aneurysm-needle,  curved  needles,  a 
grooved  director,  a  dissecting-forceps,  an  Allis  dry  dissector, 
hemostatic  forceps,  and  scissors^. 

Operation. — The  patient  is  recumbent.  He  may  be  anes- 
thetized or  Schleich's  fluid  may  be  injected.  The  operator 
stands  on  the  diseased  side.  The  assistant  stands  on  the 
sound  side  and  makes  pressure  over  the  inguinal  ring  of  the 
affected  side.  A  fold  of  skin  is  pinched  up  on  the  scrotum, 
and  the  surgeon  transfixes  it  in  the  line  of  the  cord,  so  that 
he  will  have  an  incision  about  one  and  a  half  inches  long  run- 
ning downward  from  below  the  external  ring.  The  skin  and 
fascia  are  cut  with  a  scalpel,  the  veins  are  well  exposed  by 
means  of  an  Allis  dissector,  and  the  cord  is  located  and  held 
aside.  A  double  ligature  of  strong  catgut  or  chromicized 
gut  is  passed  under  the  veins  by  an  aneurysm-needle.  The 
threads  are  separated  one  inch,  tied  tightly,  and  the  ends  are 
left  long.  The  veins  between  the  ligatures  are  excised.  The 
two  gut  ligatures  are  tied  together  and  cut.  This  shortens 
the  cord.  The  scrotum  is  sewed  up  with  silkworm-gut,  a 
small  drainage-tube  being  used  for  twenty-four  hours.  Heal- 
ing is  complete  in  one  week. 

Subcutaneous  I/igature  for  Varicocele. — In  this  ope- 
ration employ  every  antiseptic  precaution.  The  patient  stands, 
and  the  operator,  sitting  in  front  of  him,  holds  the  veins  in  a 
fold  of  skin  away  from  the  vas  deferens  by  means  of  the 
thumb  and  index  finger  of  the  left  hand.  A  large  straight 
needle  carrying  a  double  piece  of  strong  silk  is  passed  en- 
tirely through  the  scrotum,  between  the  veins  and  the  vas. 
The  needle  is  again  inserted  at  the  puncture  from  which  it 
emerged,  is  carried  around  under  the  skin  and  in  front  of  the 
veins,  and  emerges  at  its  original  point  of  entry.  The  veins 
are  thus  surrounded  by  the  silk.  The  patient,  who  now  lies 
down,  is  placed  under  the  first  stage  of  ether,  and  the  double 
ligatures  are  separated  as  far  as  possible  from  each  other, 
tied,  and  cut  off,  the  knots  slipping  in  through  the  puncture. 
This  operation  presents  certain  dangers.  The  veins  may  be 
wounded  and  the  vas  or  other  structures  may  be  included. 
In  an  operation  it  is  always  best  to  be  able  to  see  what  we 
are  doing ;  and  the  open  operation,  being  safe,  is  preferred  to 
the  subcutaneous. 

Phlebotomy,  or  Venesection. — The  instruments  used 
in  venesection  are  a  lancet  or  bistoury,  a  fillet  or  tape,  an 
antiseptic  pad,  and  a  bandage.  A  stick  should  be  at  hand 
for  the  patient  to  grasp. 


2/6 


MODERN  SURGERY. 


Fig.  54. — Superficial  veins       Fig.  55.— Incisions  for 
in  front  of  elbow.  venesection. 

(Bernard  and  Huette.) 


Operation. — The  patient  sit.s  on  a  chair  "  with  the  arm 
abducted,  extended,  and  incHned  outward  "  (Barker).  The 
parts  are  asepticized  and  a  tape  is  tied  around  the  arm  just 
above  the  elbow.  The  surgeon  stands  to  the  right  of  the 
arm,  holds  the  elbow  with  his  left  hand,  and  puts  his  thumb 

upon  the  vein  below  the 
intended  point  of  punct- 
ure. A  tape  is  tied 
above  the  elbow.  The 
patient  grasps  a  stick 
firmly  and  works  his 
fingers  to  swell  the 
veins.  Either  the  me- 
dian cephalic  or  median 
basilic  can  be  punctured 
(Fig.  54).  The  median 
basilic  is  the  more  dis- 
tinct, and  is  the  vein 
usually  selected.  In 
puncturing  it,  do  not  go 
too  deep,  as  nothing  but  the  bicipital  fascia  separates  it  from 
the  brachial  artery.  The  median  cephalic  may  be  selected 
(we  thus  avoid  endangering  the  brachial  artery) ;  under  this 
vein  lies  the  external  cutaneous  nerve  (Fig.  54).  Steady  the 
vein  with  the  thumb  and  open  it  by  transfixion,  making  an 
oblique  cut  which  divides  two-thirds  of  it.  Remove  the 
thumb  and  allow  bleeding  to  go  on,  instructing  the  patient 
to  work  his  fingers.  When  faintness  begins  remove  the  fillet, 
put  an  antiseptic  pad  over  the  puncture,  apply  a  spiral  reverse 
bandage  of  the  hand  and  arm  and  a  figure-of-8  bandage  of 
the  elbow,  and  place  the  arm  in  a  sling  for  several  days. 

Transfusion  of  Blood. — This  operation  has  been  a 
recognized  procedure  since  1824,  though  it  has  certainly 
been  known  since  1492,  when  transfusion  in  the  case  of 
Pope  Innocent  VIII.  was  made.  Its  chief  use  was  in  severe 
hemorrhage,  especially  post-partum,  in  which  it  served  to  re- 
place the  blood  lost  and  supplied  something  for  the  heart  to 
contract  upon  until  new  blood  formed.  Senn  insists  that  the 
operation  has  proved  an  absolute  failure.  It  does  not  prevent 
death  from  hemorrhage,  and  the  transferred  blood-elements 
do  not  retain  vitality.  Von  Bergmann  showed  us  that  after 
severe  hemorrhage  we  do  not  need  to  inject  nutritive  ele- 
ments, but  do  need  to  restore  the  greatly  diminished  intra- 
cardiac and  intravascular  pressure.  At  the  present  day  a 
saline  fluid  is  transfused  rather  than  blood.     In  fact,  the  ope- 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     277 

ration  of  transfusion  has  become  all  but  extinct.  It  exposes 
the  patient  to  the  danger  of  embolism  and  infection,  its 
employment  requires  material  often  hard  to  obtain,  and  it 
has  no  single  element  of  value  beyond  that  secured  by  the 
use  of  salt  solution. 

Transfusion  of  saline  fluid  is  used  after  severe  hemor- 
rhage, in  shock,  in  diabetic  coma,  in  post-operative  suppres- 
sion of  urine,  and  occasionally  in  sepsis.  After  a  hemor- 
rhage its  beneficial  effects  are  often  prompt  and  obvious. 
This  saline  fluid  increases  the  arterial  tension,  gives  the  heart 
enough  matter  to  contract  upon,  and  so  restores  the  activity 
of  the  circulation.  We  may  use  a  simple  apparatus  consist- 
ing of  a  rubber  tube,  a  funnel,  and  an  aspirating-needle.  Some 
employ  an  Aveling  syringe,  and  others  Collin's   apparatus 


Fig.  56. ^Intravenous  injection  of  saline  fluid. 

(Fig.  56).  The  last-named  instrument  can  be  used  without 
any  danger  of  air  entering  with  the  fluids.  Normal  salt  solu- 
tion is  the  fluid  usually  employed,  salt  solution  of  a  strength 
of  0.7  per  cent,  (about  a  teaspoonful  of  common  salt  to  a  pint 
of  boiled  water).  Some  surgeons  employ  an  artificial  serum 
which  contains  50  grains  of  chlorid  of  sodium,  3  grains  of 
chlorid  of  potassium,  25  grains  of  sulphate  and  25  grains  of 
carbonate  of  sodium,  2  grains  of  phosphate  of  sodium  in  a 
pint  of  boiled  water.^  Szumann's  solution  consists  of  6  parts 
of  common  salt,  i  part  of  sodium  carbonate,  and  looo  parts  of 
water.  The  following  solution  is  used  by  Locke  and  Hare : 
calcium  chlorid,  25  gm. ;  potassium  chlorid,  i  gm. ;  sodium 
chlorid,  9  gm. ;  sterile  water  sufficient  to  make  i  liter.     One 

^  A.  Pearce  Gould,  in  Treves'   System  of  Surgery. 


2/8  MODERN  SURGERY. 

bottle  of  the  commercial  fluid  when  diluted  to  i  liter  gives 
a  solution  of  the  above  composition.  Whatever  fluid  is  used, 
it  should  be  at  a  temperature  of  ioo°  F.  From  ^  pint  to 
2  pints  or  even  more  are  slowly  injected,  the  condition  of 
the  patient  determining  the  amount  given.  In  one  case  of 
violent  hemorrhage  the  author  used  2  quarts.  In  order  to 
transfuse  this  fluid  tie  a  fillet  well  above  the  elbow,  and  expose 
by  dissection  the  median  basihc  vein,  or  the  basiHc  vein  in  the 
portion  of  its  course  where  it  is  superficial  to  the  deep  fascia. 
Tie  the  vein.  Incise  it  above  the  ligature,  insert  a  fine  can- 
nula, and  hold  the  cannula  firmly  in  the  lumen  by  tightening 
a  second  ligature  (Fig.  56).  Slowly  and  gradually  introduce 
the  fluid,  carefully  watching  the  pulse.  When  the  tension 
of  the  pulse  returns  withdraw  the  cannula,  tie  the  second 
ligature  tightly,  sew  up  the  wound,  and  dress  it  aseptically. 
In  very  severe  operations  an  assistant  can  do  transfusion 
while  the  surgeon  is  operating.  It  may  be  necessary  to 
repeat  the  transfusion  if  the  circulation  fails  again. 

Arterial  Transfusion. — Hueter  preferred  the  arterial 
method  of  transfusion,  in  order  to  send  the  blood  more 
gradually  to  the  heart,  and  thus  prevent  sudden  disturb- 
ance of  the  circulation.  A  little  air  in  an  artery  will  do  no 
harm,  and  the  danger  of  venous  embolism  is  avoided.  Saline 
fluid  can  be  thrown  into  an  artery.  The  radial  artery  is 
exposed  and  surrounded  by  three  ligatures,  and  the  thread 
toward  the  heart  is  at  once  tied.  The  distal  ligature  is 
slightly  tightened  to  cut  off  anastomotic  blood-supply. 
The  artery  is  cut  transversely  half  through ;  the  syringe  is 
inserted,  pointed  toward  the  periphery,  and  fastened  by  the 
third  ligature ;  the  second  ligature  is  loosened  and  the  blood 
is  injected.  On  finishing,  the  peripheral  thread  is  tied 
tightly  and  that  portion  of  the  artery  which  held  the 
cannula  is  excised. 

3.  Ligation  of  Arteries  in  Continuity. 
The  instruments  used  in  this  operation  are  two  scalpels 


j^j^M 


Fig.  57. — Aneurysm-needle  of  Saviard. 

(one    small,  one    medium),  two    dissecting-forceps,  several 
hemostatic  forceps,  toothed  forceps,  blunt  hooks  or  broad 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     279 


Fig.  58. 


-Dupuytren's  aneurysm- 
needles. 


metal  retractors,  an  Allis  dissector,  an  aneurysm-needle,  for 
superficial  arteries  the  instrument  of  Saviard  (Fig.  57),  for 
deep  vessels  the  needle  of  Dupuy- 
tren  (Fig.  58),  ligatures  of  catgut, 
of  chromicized  gut,  or  of  silk, 
curved  needles  and  needle-holder, 
and  silkworm-gut,  and  the  reflec- 
tor or  electric  forehead-lamp  for 
deep  vessels. 

The  position  varies  according 
to  the  vessel,  though  the  body  is 
supine  except  when  ligation  is  to 
be  performed  on  the  gluteal, 
sciatic,  or  popliteal.  The  opera- 
tor, as  a  rule,  stands  upon  the 
affected  side,  cutting  from  above 
downward  on  the  right  side  and 
from  below  upward  on  the  left  side. 

Operation. — Accurately  determine  the  line  of  the  artery, 
and  make  an  incision  at  a  slight  angle  to  this  line,  avoid- 
ing subcutaneous  veins,  and  holding  the  scalpel  like  a  fiddle- 
bow  or  a  dinner-knife  while  cutting  the  superficial  parts, 
and  like  a  pen  while  incising  the  deeper  parts.  On  reaching 
the  deep  fascia  make  out  the  required  muscular  gap  by  the 
eye  and  finger,  so  moving  the  extremity  as  to  bring  indi- 
vidual muscles  into  action.  Treves  cautions  us  not  to 
depend  upon  the  yellow  line  of  fat,  which  often  cannot  be 
seen  in  emaciated  people  or  when  an  Esmarch  bandage 
is  employed ;  nor  upon  the  white  line  due  to  attachment  to 
the  fascia  of  an  intermuscular  septum.  In  opening  the  deep 
portion  of  the  wound  relax  the  bounding  muscles  by  altering 
the  posture.  Open  a  muscular  interspace  with  a  sharp  knife, 
not  with  a  dissector.  Make  the  depths  of  the  wound  as  long 
as  the  superficial  incision.  Do  not  tear  structures  apart 
with  a  grooved  director ;  cut  them.  Arrest  hemorrhage  as 
it  occurs.  Try  to  find  the  situation  of  the  artery  with  the 
finger.  Pulsation  is  present,  but  it  may  be  very  feeble  and 
hard  to  detect.  The  artery  feels  like  a  very  thin  rubber 
tube ;  it  is  compressible,  though  not  so  easily  as  a  vein, 
and  when  compressed  feels  like  a  flat  band  which  is  thinner 
in  the  center  than  at  the  edges  (Treves).  A  nerve  feels  like 
a  hard  round  cord.  The  veins  are  soft,  larger  than  their 
related  arteries,  and  so  very  compressible  that  they  can 
scarcely  be  felt  when  pressed  upon,  compression  causing 
distal  distention.     If  the  wound  can  be  seen  well  into,  it  will 


28o  MODERN  SURGERY. 

be  noted,  as  Treves  asserts,  that  "  the  nerves  stand  out  as 
clear,  rounded,  white  cords ;  that  the  veins  are  of  a  purple 
color  and  of  somewhat  uneven  and  wavy  contour ;  that  the 
artery  is  regular  in  outline  and  of  a  pale-pink  or  pinkish- 
yellow  tint,  the  large  vessels  being  of  lighter  color  than  the 
small."  All  the  arteries  of  the  upper  extremity  and  all  the 
arteries  below  the  knee  are  accompanied  by  two  veins,  known 
as  "  venae  comites."  The  arteries  of  the  head  and  neck 
have  each  a  single  attending  vein,  except  the  lingual,  which 
has  vense  comites.  Most  of  the  smaller  arteries  of  the  trunk 
(pudic,  internal  mammary,  etc.)  have  venae  comites.  These 
companion  veins  may  lie  on  each  side  of  the  artery  or  in 
front  and  back  of  it,  and  they  communicate  with  one  another 
by  transverse  branches  crossing  the  artery.  On  reaching 
the  sheath  pick  up  this  structure  with  toothed  forceps  so 
as  to  make  a  transverse  fold,  and  thus  avoid  catching  the 
artery  or  vein ;  lift  the  fold  to  see  that  it  is  free,  and  open 
the  sheath  by  cutting  toward  the  edge  of  the  forceps  with 
a  scalpel  held  obliquely  with  its  back  toward  the  vessel,  thus 
making  a  small  longitudinal  incision  (PL  i,  Figs,  i,  2).  Hold 
the  edge  of  the  incised  sheath  with  the  forceps ;  pass  an 
Allis  dissector  under  the  vessel  and  from  the  forceps ;  this 
clears  one-half  of  the  vessel.  Grasp  the  other  edge  of  the 
sheath  and  pass  the  blunt  dissector  all  the  way  around  the 
vessel.  Pass  an  aneurysm-needle  under  the  cleared  vessel 
away  from  the  forceps  holding  the  sheath.  Thread  the  needle 
and  withdraw  it  always  from  its  most  dangerous  neighbor.  If 
venae  comites  are  in  the  way,  try  to  separate  them  ;  but  if  this 
proves  difficult,  include  them  in  the  ligature.  In  small  ves- 
sels always  include  them  if  they  are  in  the  way,  as  this  saves 
trouble.  If,  in  passing  the  needle,  a  large  vein  is  severely 
wounded  (such  as  the  femoral),  Jacobson  advises  the  em- 
ployment of  digital  pressure  in  the  lower  portion  of  the 
wound  while  the  artery  is  being  tied  on  a  level  above  or 
below  that  of  the  vein-injury,  and  after  ligation  the  main- 
tenance of  pressure  on  the  wound  for  a  couple  of  days.  A 
slight  puncture  in  a  vein  merely  requires  a  lateral  ligature. 
A  small  longitudinal  cut  can  be  closed  with  Lembert  sutures 
of  fine  silk.  After  getting  a  ligature  under  an  artery  press 
for  a  moment  upon  the  artery  over  the  ligature,  which  is 
held  taut ;  this  pressure  will  arrest  pulsation  below  if  the 
ligature  is  around  the  main  artery  and  there  is  not  a  double 
vessel.  Tie  the  thread  at  right  angles  to  the  vessel  with  a 
reef-knot  (Fig.  59),  rupturing  the  internal  and  middle  coats. 
As  the  ligature  is  tightened  place  the  extended  index  fingers 


LIGATIONS. 


Plate  i. 


1.  Opening  the  Sheath  for  Ligation  of  an  Artery  (Guerin).  2.  Sheath  of  Artery  Open  (Guerin). 
3.  Tightening  the  Knot  in  Ligation  (Guerin).  4.  Anatomy  of  the  Iliac  Arteries,  and  showing  the 
lines  of  incision  for  their  ligation  :  i,  Abernethy's  incision  (Guerin).  5,  6.  Hallance  and  Ed 
mund's  Stay-knots. 


DISEASES  AND   INJURIES   OE  HEART  AND    VESSELS     28 1 


along  the  ligature  up  to  the  artery  (PI.  i,  Fig.  3),  using  the 
middle  joints  as  the  fulcrum  of  a  lever  by  placing  them 
against  each  other. 

Ballance  and  Edmunds  have  recently  claimed,  as  Scarpa 
and  Sir  Philip  Crampton  did  long  since,  that  it  is  not  neces- 
sary to  divide  the  internal  and  middle  coats  to  insure  oblit- 
eration. If  this  claim  be  true,  the  danger  of  secondary 
hemorrhage  can  be  greatly  lessened. 
Holmes,  however,  thinks  the  older 
method  the  more  certain  of  the  two. 
Ballance  and  Edmunds  recommend  that 
the  artery  be  surrounded  with  a  doubled 
ligature  of  floss-silk,  that  each  ligature  be 
tied  with  one  turn  of  a  reef-knot,  and  that 


Fig.  59. — Reef-knot. 


Fig.  60. —  Diagram  showing  the 
action  of  the  ligature. 


the  final  turn  be  made  by  gathering  together  as  single  pieces 
both  ends  on  either  side,  and  tying  them  to  each  other.  This 
knot  is  known  as  the  "  stay-knot"  (PI.  i.  Figs.  5,  6). 

The  chief  dangers  after  ligation  are  secondary  hemor- 
rhage and  gangrene.  Rigid  asepsis  usually  prevents  the 
first ;  rest,  elevation,  and  heat  antagonize  the  second. 

Radial  Artery. — The  line  of  the  radial  arter>'  is  from 
the  middle  of  the  front  of  the  elbow-joint  to  the  ulnar  side 
of  the  styloid  process  of  the  radius.  The  line  in  the  tab- 
atiere  is  from  the  apex  of  the  styloid' process  to  the  posterior 
angle  of  the  first  interosseous  space. 

Anatomy  (PL  2,  Fig.  5). — The  radial  artery,  though  smaller 
than  the  ulnar,  is  the  direct  continuation  of  the  brachial. 
It  arises  from  the  bifurcation  of  the  brachial  half  an  inch 
below  the  bend  of  the  elbow,  runs  down  the  radial  side  of 
the  forearm  to  the  front  of  the  styloid  process  of  the  radius, 
passes  beneath  the  extensor  muscles  of  the  first  metacarpal 
bone  and  of  the  first  phalanx  of  the  thumb,  and  over  the 
carpus  to  the  first  interosseous  space.  It  is  crossed  by  the 
tendon  of  the  extensor  secundi  internodii  pollicis,  enters  into 
the  palm  between  the  heads  of  the  first  dorsal  interosseous 
muscle,  and  forms  the  deep  palmar  arch.     The  artery  in  the 


282  MODERN  SURGERY.    . 

upper  two-thirds  of  its  course  is  somewhat  overlaid  by  the 
supinator  longus  muscle ;  in  the  lower  one-third  of  the  fore- 
arm it  is  superficial.  In  the  upper  third  of  the  forearm  it 
lies  between  the  supinator  longus  on  the  outside  and  the 
pronator  radii  teres  on  the  inside ;  in  the  lower  two-thirds 
of  the  forearm  it  lies  between  the  supinator  longus  on  the 
outside  and  the  flexor  carpi  radialis  on  the  inside.  Two 
venae  comites  attend  the  vessel.  The  radial  nerve  is  to  the 
outer  or  radial  side  of  the  artery,  well  removed  from  the 
artery  in  the  upper  third,  nearer  to  the  artery  in  the  middle 
third,  far  external  to  the  artery  in  the  lower  third,  the  nerve 
at  this  point  passing  beneath  the  supinator  longus  muscle. 
The  radial  artery,  from  above  downward,  rests  upon  the 
biceps  tendon,  the  supinator  brevis,  the  flexor  sublimis,  the 
pronator  radii  teres,  the  flexor  longus  pollicis,  the  pronator 
quadratus  muscles,  and  the  radius.  It  has  two  venae  comites. 
The  best  guide  to  the  radial  artery  in  the  forearm  is  the 
outer  edge  of  the  flexor  carpi  radialis  muscle  or  the  inner 
edge  of  the  supinator  longus  muscle. 

The  tabatiere  anatomique  of  Cloquet,  or  the  anatomical 
snuff-box,  is  a  triangle  whose  base  is  the  lower  edge  of  the 
posterior  annular  ligament,  the  ulnar  side  being  formed  by 
the  extensor  secundi  internodii  pollicis  tendon,  the  radial 
side  by  the  extensor  ossis  metacarpi  and  the  extensor  primi 
internodii  pollicis  tendons  ;  the  floor  consists  of  the  trape- 
zium, scaphoid,  their  dorsal  ligaments,  and  the  base  of  the 
first  metacarpal  bone. 

Operations. — Ligation  in  the  tabatiere  is  a  dissecting-room 
operation  of  but  little  practical  use.  The  patient  is  placed 
in  a  recumbent  position,  the  arm  is  abducted  and  the  forearm 
is  placed  midway  between  pronation  and  supination  (Barker). 
The  surgeon  stands  upon  the  side  operated  upon.  An  in- 
cision two  inches  in  length  is  made  along  the  radial  border 
of  the  extensor  secundi  internodii  pollicis  muscle.  The  skin 
and  superficial  fascia  are  cut  and  some  venous  branches  are 
divided.  The  deep  fascia  is  incised  and  the  vessel  is  easily 
found  and  tied  before  it  passes  between  the  heads  of  the 
first  dorsal  interosseous  muscle  (Barker). 

Ligation  in  the  Lower  Third. — In  this  operation  (PI.  2, 
Fig.  6)  the  patient  is  supine,  the  arm  is  abducted,  the  fore- 
arm is  supinated  and  rested  upon  a  table  and  held  by  an 
assistant.  The  surgeon  stands  on  the  side  operated  upon, 
and  cuts  from  above  downward  on  the  right  arm  and  from 
below  upward  on  the  left  arm.  The  line  of  the  vessel  is 
determined,  and   can  be  marked  with  iodin  or  anilin.     An 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     283 

incision  one  and  a  half  inches  long  is  made  at  a  slight  angle 
to  this  line  and  midway  between  the  supinator  longus  and 
the  flexor  carpi  radialis  muscles,  which  incision  must  not 
extend  below  the  level  of  the  tuberosity  of  the  scaphoid 
bone.  In  the  superficial  fascia  watch  for  the  superficial 
radial  vein,  and  if  it  comes  into  view,  push  it  aside.  Incise 
the  superficial  fascia  and  locate  each  guide-tendon.  Open 
the  deep  fascia  in  the  length  of  the  first  cut;  try  to 
separate  the  veins,  but  if  they  strongly  adhere,  include 
them  in  the  ligature.  There  is  no  special  fascial  sheath. 
The  radial  nerve  will  not  be  seen,  but  a  division  of  the 
anterior  cutaneous  is  frequently  found  in  relation  with  the 
vessel.  The  needle  can  be  passed  in  either  direction.  A 
high  origin  of  the  superficialis  volae  artery  is  confusing. 

Ligation  in  the  Middle  Third. — In  this  operation  the  posi- 
tion is  the  same  as  in  the  preceding.  A  two-inch  incision 
is  made.  Veins-  of  the  subcutaneous  tissues  are  avoided. 
Lying  upon  the  deep  fascia  is  the  anterior  division  of  the 
musculocutaneous  nerve.  Open  the  fascia ;  find  the  inner 
edge  of  the  supinator  longus  muscle  and  draw  it  outward, 
flexing  the  elbow  if  necessary.  Be  sure  not  to  get  external 
to  this  muscle.  Find  the  vessel  where  it  is  bound  down  by 
connective  tissue  to  the  pronator  radii  teres  muscle,  separate 
the  veins,  and  pass  the  ligature  from  without  in.  The  nerve 
is  external. 

Ligation  in  the  Upper  Third  (PI.  2,  Fig.  6). — In  this  ope- 
ration the  incision  is  like  the  last,  only  higher  up.  The 
artery  is  between  the  supinator  longus  and  the  pronator 
radii  teres,  which  muscles  are  at  once  differentiated  by  the 
different  direction  of  their  fibers.  The  artery  is  usually  cov- 
ered by  the  supinator  longus  muscle,  which  must  be  retracted 
externally.  The  nerve  is  not  seen.  The  ligature  is  passed 
in  either  direction. 

Ulnar  Artery. — No  one  lijie  will  overlie  the  entire  ulnar 
artery.  The  line  of  the  upper  third  runs  from  the  middle  of 
the  front  of  the  elbow-joint  to  the  point  of  junction  of  the 
upper  and  middle  thirds  of  the  ulna.  The  line  of  the  lower 
two-thirds  runs  from  the  tip  of  the  internal  condyle  of  the 
humerus  to  the  radial  side  of  the  pisiform  bone  (PI.  2,  Figs. 
5,  6). 

Anatomy  (PI.  2,  Fig.  5). — The  ulnar  artery  arises  from 
the  brachial  bifurcation  and  runs  obliquely  inward  under  the 
median  nerve  and  a  group  of  muscles  from  the  internal  con- 
dyle ;  it  turns  down  the  arm,  being  covered  in  the  middle 
third  of  its  course  by  the  flexor  carpi  ulnaris  muscle.     In  the 


284  MODERN  SURGERY. 

lower  third  it  is  superficial,  between  the  tendons  of  the  flexor 
carpi  ulnaris  on  the  inside  and  the  flexor  sublimis  digitorum 
on  the  outside,  the  vessel  being  a  little  overlapped  by  the 
flexor  carpi  ulnaris.  This  vessel  rests  first  upon  the  brachi- 
alis  anticus  muscle,  next  upon  the  flexor  profundus,  to  which 
it  is  bound  by  a  distinct  process  of  fascia,  and  next  upon  the 
annular  ligament,  which  structure  it  crosses  to  become  the 
superficial  palmar  arch.  Two  venae  comites  attend  the  vessel. 
In  the  upper  third  the  nerve  is  well  internal,  but  in  the  lower 
two-thirds  the  nerve  lies  near  the  artery  and  to  its  ulnar  side. 
The  guide  is  the  outer  edge  of  the  flexor  carpi  ulnaris. 

Operations  (PI.  2,  Fig.  6). — Ligation  of  the  Lower  Tliird. 
— The  position  in  this  operation  is  the  same  as  for  the  radial 
artery.  Make  a  two-inch  incision  to  the  radial  side  of  the  ten- 
don of  the  flexor  carpi  ulnaris,  which  incision  is  not  taken 
lower  than  a  point  one  inch  above  the  pisiform  bone.  Avoid 
the  superficial  ulnar  vein  in  the  subcutaneous  tissue.  Open 
the  deep  fascia,  find  the  tendon  of  the  flexor  carpi  ulnaris, 
flex  the  wrist  and  draw  the  tendon  inward,  open  a  second 
layer  of  fascia,  clear  the  vessel,  separate  the  veins,  and  pass 
the  ligature  from  within  outward  to  avoid  the  nerve.  On 
the  artery  is  the  palmar  cutaneous  branch  of  the  ulnar 
nerve,  and  this  branch  must  not  be  included  in  the 
ligature. 

Ligation  of  the  Middle  Third  (PI.  2,  Fig.  6). — In  this  opera- 
tion the  position  is  the  same  as  in  the  preceding  one,  the  in- 
cision being  three  inches  long.  Avoid  the  anterior  ulnar  vein 
and  the  branches  of  the  internal  cutaneous  nerve  in  the  super- 
ficial fascia.  Open  the  deep  fascia  a  little  external  to  the 
superficial  cut  (Treves).  Find  the  space  between  the  flexor 
carpi  ulnaris  and  the  superficial  flexor,  feeling  with  the  index 
finger,  and  when  the  space  is  discovered  flex  the  wrist,  re- 
tract the  flexor  carpi  ulnaris  inward  and  the  flexor  sublimis 
digitorum  outward,  open  the  fascia,  find  the  ulnar  nerve,  look 
external  to  it  for  the  artery,  clear  the  vessel,  separate  the 
venae  comites,  and  pass  the  needle  from  within  outward.  The 
ulnar  artery  should  not  be  ligated  in  continuity  in  the  upper 
one-third  of  its  course. 

Brachial  Artery. — The  line  of  the  brachial  artery  is  from 
the  junction  of  the  anterior  and  middle  thirds  of  the  outlet 
of  the  axilla,  the  arm  being  abducted  and  the  forearm  supi- 
nated,  to  the  middle  of  the  front  of  the  elbow-joint. 

Anatomy  (PI.  2,  Fig.  i). — The  brachial  artery  is  the  pro- 
longation of  the  axillary,  and  extends  from  the  lower  edge  of 
the  teres  major  muscle  to  half  an  inch  below  the  bend  of  the 


LIGATIONS. 


Plate  2. 


ntf'X^ 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     285 

elbow,  where  it  divides  into  the  radial  and  ulnar.  It  lies  first 
to  the  inner  side  of  the  arm,  but  passes  to  the  front  of  the 
elbov\^  It  is  crossed  by  no  muscle,  and  is  in  fact  superficial, 
barring  its  being  somewhat  overlaid  in  part  of  its  course  by 
the  edge  of  the  biceps  muscle.  The  median  nerve  is  outside 
above,  crosses  over  it  about  the  middle  of  the  arm,  and 
reaches  the  inside.  The  coracobrachialis  and  biceps  mus- 
cles are  external,  and  both  often  overlap  the  vessel.  The 
ulnar  nerve  is  internal  above,  and  the  median  nerve  below, 
the  middle.  The  basilic  vein  is  internal  to  the  artery,  being 
outside  the  deep  fascia  to  near  the  middle  of  the  arm,  at 
which  point  it  pierces  it.  The  artery  above  is  separated  from 
the  long  head  of  the  triceps  by  the  musculospiral  nerve  and 
superior  profunda  artery  and  vein  ;  it  rests  from  above  down 
on  the  inner  head  of  the  triceps,  the  coracobrachialis,  and 
the  brachialis  anticus.  The  artery  is  covered  by  skin  and  by 
superficial  and  deep  fascia.  The  internal  cutaneous  nerve  lies 
in  front  of  the  artery,  upon  the  deep  fascia,  until  it  pierces 
the  fascia  along  with  the  basilic  vein.  The  artery  has  venae 
comites,  and  in  its  upper  half  has  also  the  basilic  vein  to  its 
inner  side.  The  guide  to  the  brachial  is  the  inner  edge 
of  the  biceps  muscle.  Just  in  front  of  the  elbow-joint  the 
artery  lies  in  a  triangle,  the  base  of  which  is  formed  by  an 
imaginary  transverse  line  above  the  condyles,  the  apex  by 
the  junction  of  the  pronator  radii  teres  and  the  supinator 
longus.  The  outer  line  is  the  supinator  longus,  the  inner 
line  is  the  pronator  radii  teres,  and  the  floor  is  formed  by  the 
brachialis  anticus  and  the  supinator  brevis.  From  within 
outward  the  triangle  contains  the  median  nerve,  brachial 
artery,  tendon  of  the  biceps,  anastomosis  of  the  superior 
profunda  and  radial  recurrent  arteries,  and  the  musculospiral 
nerve. 

Operations. — Ligation  at  the  Bend  of  the  Elboiv. — In  this 
operation  (PI.  2,  Fig.  2)  the  patient  is  supine,  the  arm  is  mod- 
erately abducted  and  extended,  and  is  allowed  to  lie  upon  its 
posterior  aspect.  The  forearm  is  supinated.  The  surgeon 
stands  upon  the  side  operated  upon,  and  cuts  from  above 
downward  on  the  right  side  and  from  below  upward  on  the 
left  side.  Accurately  locate  the  tendon  of  the  biceps  and  the 
median  basilic  vein.  An  incision  is  made  parallel  with  the 
inner  edge  of  the  biceps  tendon  and  two  inches  in  length, 
the  center  of  this  cut  being  in  the  crease  of  the  elbow.  On 
exposing  the  median  basilic  vein,  retract  it  downward  and  in- 
ward, open  the  bicipital  fascia,  clear  the  artery  of  fat,  separate 
the  venae  comites,  and  pass  the  ligature  from  within  outward 


286  MODERN  SURGERY. 

to  avoid  the  median  nerve.  The  above  operation  is  not  fre- 
quently performed. 

Ligation  in  the  Middle  of  the  Arm. — In  this  operation  the 
patient  is  placed  supine  and  abduction  of  the  arm  and  supi- 
nation of  the  forearm  are  brought  about.  An  assistant  holds 
the  forearm,  but  the  arm  should  not  rest  upon  the  table, 
because,  if  it  be  allowed  to  do  so,  the  inner  head  of  the 
triceps  will  be  forced  forward  and  may  overKe  the  artery,  and 
thus  complicate  the  operation.  Locate  the  inner  edge  of  the 
biceps,  which  is  the  guide.  Make  an  incision  three  inches 
long  in  the  Hne  of  the  artery.  Incise  the  skin  and  fascia, 
flex  the  elbow  slightly,  retract  the  biceps  outward,  feel  for 
the  artery,  open  its  sheath,  separate  its  vense  comites,  and, 
having  located  the  median  nerve,  pass  the  ligature  from  it. 
In  the  middle  of  the  arm  the  nerve  is  in  front  of  the  vessel, 
above  the  middle  it  is  external,  and  below  the  middle  internal. 
High  up  the  arm  the  inner  edge  of  the  coracobrachialis  is 
the  guide,  rather  than  the  biceps.  Above  the  middle  of  the 
arm  the  basilic  vein  is  beneath  the  deep  fascia  and  runs  along 
to  the  inner  side  of  the  artery ;  hence,  high  up,  the  artery 
has  three  companion  veins,  the  venae  comites  and  the  basilic 
vein,  and  there  is  seen  the  ulnar  nerve  to  the  inside  of  the 
artery. 

Axillary  Artery. — To  determine  the  line  of  the  axillary 
artery  place  the  arm  at  right  angles  to  the  body,  with  the 
patient  supine,  and  lay  down  a  line  from  the  middle  of  the 
clavicle  to  the  humerus  near  the  inner  border  of  the  coraco- 
brachialis. The  line  of  the  third  portion  can  be  approximated 
by  projecting  the  line  of  the  brachial  upward. 

Anatomy  (PL  2,  Fig.  3 ;  PI.  3,  Fig.  i). — The  axillary  artery 
is  the  continuation  of  the  subclavian,  and  runs  from  the  lower 
margin  of  the  first  rib  to  the  inferior  border  of  the  teres  major 
muscle.  It  is  divided  into  three  portions  by  the  pectoralis 
minor  muscle.  The  first  portion  is  above,  the  second  por- 
tion is  behind,  and  the  third  portion  is  below,  the  pectoralis 
minor.  The  position  of  the  artery  varies  with  the  position 
of  the  limb.  When  the  arm  is  parallel  with  the  body  the 
artery  is  far  from  the  surface  and  forms  a  curve  whose  con- 
vexity is  upward  and  outward.  When  the  arm  is  at  right 
angles  to  the  body  the  vessel  is  nearer  the  surface  and 
straight.  When  the  arm  is  raised  above  a  right  angle  the 
artery  comes  near  the  surface  and  forms  a  curve  with  the 
convexity  downward. 

The  first  portion  of  the  axillary  artery  is  occasionally 
ligated.      It  lies   upon  the  first  intercostal  muscle  and  the 


DISEASES  AXD   IXJURIES   OF  HEART  AND    VESSELS.     28/ 

first  serration  of  the  great  scrratus  muscle,  and  has  behind 
it  the  posterior  thoracic  nerve  ;  the  brachial  plexus  is  external 
and  posterior  to  the  vessel ;  on  its  inner  side  is  the  axillary 
vein  ;  in  front  of  it  are  the  clavicle,  the  great  pectoral  muscle, 
the  subclavius  muscle,  the  costocoracoid  membrane,  the 
cephalic  and  acromiothoracic  veins,  and  the  external  anterior 
thoracic  nerve.  The  branches  of  the  first  part  of  the  axillary 
artery  are  the  superior  thoracic  and  the  acromiothoracic.  The 
second  part  of  the  artery  is  not  ligated.  The  brachial  plexus 
surrounds  the  second  portion.  The  third  part  is  covered  in 
front,  above,  by  the  great  pectoral,  but  is  covered  below  by 
skin  and  fascia  ;  behind,  it  has  the  tendon  of  the  subscapularis, 
the  latissimus  dorsi,  and  the  teres  major ;  the  coracobrachi- 
alis  is  on  the  outer  side ;  the  axillary  vein  is  on  the  inner 
side.  It  is  important  to  remember  that  there  may  be  three 
veins,  one  external  and  two  internal.  The  axillary  vein  is 
formed  by  the  venae  comites  of  the  brachial  artery  joining, 
and  this  new  vein  effecting  a  junction  with  the  basilic  vein. 
The  median"  nerve  lies  upon  the  axillary  artery  in  the  upper 
part  of  the  third  portion  of  the  vessel's  course,  and  passes  to 
the  outer  side.  The  musculocutaneous  nerve  is  external, 
but  it  is  only  seen  high  up ;  the  ulnar  nerve  is  internal ;  the 
lesser  internal  and  the  internal  cutaneous  nerves  are  internal ; 
the  musculospiral  and  the  circumflex  nerv^es  are  behind.  The 
branches  of  the  third  portion  of  the  axillary  artery  are  the 
subscapular  and  the  anterior  and  posterior  circumflex. 

Operations. — Ligation  of  the  Third  Portion  (PL  2,  Fig.  4). 
— The  position  in  this  operation  is  supine  with  the  shoulders 
raised  and  the  arm  abducted  to  a  right  angle.  The  surgeon 
stands  between  the  patient's  arm  and  side,  with  his  back  to- 
ward the  subject's  feet.  An  incision  is  made  three  inches  in 
length.  It  begins  half-way  up  the  axilla  opposite  to  the  head 
of  the  humerus,  and  comes  downward  parallel  to  the  lower 
edge  of  the  great  pectoral  muscle  and  crosses  the  junction 
of  the  anterior  and  middle  thirds  of  the  outlet  of  the  axilla. 
Incise  the  integuments  and  fascia.  The  vein  or  veins  will  be 
prominent  to  the  inner  side  and  may  overlie  the  vessel.  To 
the  inner  side  with  the  veins  are  the  ulnar  and  internal  cu- 
taneous nerves.  The  median  is  upon  and  the  external  cuta- 
neous nerve  to  the  outer  side  of  the  artery.  Feel  for  the 
pulsations  of  the  artery,  find  the  median  nerve  and  draw  it 
outward,  draw  the  internal  nerve  and  veins  inward,  clear  the 
artery  from  the  venae  comites.  and  pass  the  ligature  from 
within  outward.  Apply  the  ligature  well  below  the  cir- 
cumflex branches. 


288  MODERN  SURGERY. 

Ligation  of  tJie  First  Pm't. — This  operation  (PI.  3,  Fig.  2) 
was  first  performed  in  181 5  by  Chamberlaine  of  Jamaica. 
The  position  is  supine,  the  upper  part  of  the  body  being 
raised,  a  sand-pillow  being  placed  between  the  scapulae  to 
insure  carrying  back  of  the  point  of  the  shoulder,  and  the 
arm  being  brought  down  along  the  side.  In  operating  on  the 
left  side  the  surgeon  stands  on  the  outer  side  of  the  left  arm ; 
in  operating  on  the  right  side  he  stands  to  the  right  of  the 
subject's  head  and  leans  over  his  shoulder.  The  incision, 
which  is  slightly  curved  downward,  begins  external  to  the 
sternoclavicular  joint  and  ends  internal  to  the  margin  of  the 
deltoid,  thus  avoiding  the  cephalic  vein.  The  incision  is  half 
an  inch  below  the  clavicle.  Incise  skin,  platysma  myoides 
muscle,  superficial  nerves,  and  deep  fascia.  In  the  outer  angle 
of  the  wound  watch  out  for  the  acromiothoracic  artery  and 
the  cephalic  vein.  Incise  the  pectoralis  major ;  draw  the  pec- 
toralis  minor  down  ;  retract  the  lower  margin  of  the  wound, 
cut  throup-h  the  costocoracoid  membrane  close  to  the  cora- 
coid  process  and  upper  border  of  the  lesser  pectoral.  Bring 
the  arm  to  the  side  so  as  to  relax  the  structures.  Find  the 
brachial  plexus,  feel  for  the  artery  internal  to  it,  clear  the 
vessel,  draw  the  vein  internally,  and  pass  the  needle  from 
within  outward.  This  avoids  the  dangerous  neighbor,  which 
is  the  axillary  vein.  This  operation  is  difficult,  dangerous, 
and  unusual,  and  in  its  performance  the  axillary  vein,  which 
has  a  close  attachment  to  the  costocoracoid  membrane,  is 
apt  to  be  torn. 

Subclavian  Artery. — There  is  no  line  for  this  vessel. 

Anatomy  (PI.  3,  Fig.  i). — The  subclavian  artery  of  the 
right  side  arises  from  the  innominate ;  of  the  left  side,  from 
the  arch  of  the  aorta.  The  subclavian  is  divided  into  three 
parts.  The  first  part  runs  from  the  origin  of  the  vessel  to  the 
inner  border  of  the  scalenus  anticus  muscle  ;  the  second  part 
lies  behind  the  scalenus  anticus  muscle ;  and  the  third  part 
runs  from  the  outer  edge  of  the  muscle  to  the  lower  border 
of  the  first  rib. 

At  the  present  day  the  first  and  second  portions  are  not 
ligated.  The  third  portion  is  contained  in  the  subclavian 
triangle  (Fig.  61),  and  is  superficial.  It  rises,  as  a  rule,  to 
half  an  inch  above  the  clavicle.  The  subclavian  vein  is  below 
the  artery,  being  separated  from  it  by  the  scalenus  anticus 
muscle.  The  brachial  plexus  is  above  and  external  to  the 
artery.  The  vessel  rests  upon  the  first  rib,  and  behind  it  is 
the  scalenus  medius  muscle.  The  suprascapular  and  trans- 
versalis  colli  arteries  and  veins  and  branches  of  the  cervical 


LIGATIONS. 


Plate  3. 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     289 

plexus  lie  in  front  of  the  artery,  and  the  external  jugular 
vein  crosses  it  at  its  inner  side.  The  third  portion  gives  off 
no  branches. 

Ligation  of  the  Third  Part. — This  operation  (PI.  3,  Fig.  2) 
was  first  successfully  performed  in  181 7  by  Post  of  New  York. 
The  position  is  as  follows  :  place  the  patient  upon  his  back, 
raise  the  shoulders,  extend  and  turn  the  head  toward  the 
opposite  side,  pull  down  the  arm,  and  hold  it  by  pushing  the 
forearm  under  the  patient's  back  (Treves).  This  pulls  down 
the  clavicle,  thus  increasing  the  size  of  the  subclavian  tri- 
angle. The  operator  stands  facing  the  shoulder,  with  his 
back  toward  the  patient's  feet.  Draw  the  skin  over  the  sub- 
clavian triangle,  half  an  inch  above  the  clavicle,  down  upon 
this  bone,  and  incise.  This  maneuver  avoids  the  external 
jugular  vein  and  gives  an  incision  half  an  inch  above  the 
collar-bone.  The  incision  reaches  from  the  anterior  edge  of 
the  trapezius  to  the  posterior  border  of  the  sternocleidomas- 
toid (PI.  3,  Fig.  2),  and  is  about  three  inches  long.  By  this  in- 
cision are  divided  the  skin,  the  superficial  fascia,  the  platysma 
myoides,  the  vein  running  from  the  cephalic  to  the  external 
jugular,  and  some  superficial  nerves.  Open  the  deep  fascia. 
Draw  the  external  jugular  vein  into  the  inner  angle  of  the 
wound,  and  do  not  divide  it  unnecessarily  ;  if  forced  to  do  so, 
tie  the  vein  with  two  ligatures  and  cut  between  them.  Find 
the  outer  edge  of  the  anterior  scalene  muscle,  and  run  the 
finger  down  along  it  to  the  tubercule  on  the  first  rib.  Draw 
up  the  posterior  belly  of  the  omohyoid  muscle.  With  the 
finger  on  the  tubercle  recall  the  fact  that  the  vein  is  in  front 
of  the  finger  and  the  artery  is  behind  it,  and  that  the  sub- 
clavian vein  is  on  a  lower  plane  than  the  artery.  The  artery 
is  felt  beating  as  it  lies  upon  the  rib.  Clear  the  artery  and 
expose  the  lower  cord  of  the  brachial  plexus.  Guard  the 
vein  with  the  finger  and  pass  the  needle  from  above  down- 
ward, as  the  plexus,  which  is  in  more  danger  than  the  vein, 
is  to  be  avoided.  In  this  operation  never  cut  the  transversa- 
lis  colli  or  suprascapular  arteries,  as  they  are  necessary  to 
the  future  anastomotic  circulation.  If  the  field  of  operation 
is  too  small,  incise  the  trapezius  or  sternocleidomastoid  or 
both. 

The  vertebral  artery  was  first  successfully  ligated  by 
Smyth  of  New  Orleans. 

Anatomy. — This  vessel  is  the  largest  branch  of  the  sub- 
clavian, and  is  the  first  branch  from  the  first  portion  of  the 
subclavian.  The  vertebral  artery  ascends  and  enters  the 
foramen  in  the  transverse  process  of  the  sixth  cervical  vcr- 

19 


290  MODERN  SURGERY. 

tebra  (in  rare  cases  the  fifth  or  the  seventh),  and  ascends 
through  foramina  in  the  cervical  vertebrae,  passes  behind  the 
articular  process  of  the  atlas  and  over  the  posterior  arch  of 
this  first  vertebra,  pierces  the  posterior  occipito-atloid  liga- 
ment, and  enters  the  skull  by  way  of  the  foramen  magnum 
(see  Gray).  It  joins  its  fellow  of  the  opposite  side  to  form 
the  basilar.  At  its  point  of  origin  it  has  in  front  of  it  the 
internal  jugular  vein  and  inferior  thyroid  artery.  Gray  says 
that  near  the  spine  it  lies  between  the  longus  colli  and 
scalenus  anticus  muscles,  with  the  thoracic  duct  to  the  left 
and  in  front. 

Ligation. — Position  as  for  ligation  of  carotid.  Make  an 
incision  three  inches  in  length  along  the  posterior  edge  of 
the  sternocleidomastoid  muscle.  This  incision  reaches  the 
clavicle.  In  dividing  the  skin  and  superficial  fascia  watch 
for  the  external  jugular  vein  and  retract  it  inward.  Divide 
the  deep  fascia.  Retract  the  sternocleido  inward.  Open 
the  space  between  the  longus  colli  and  scalenus  anticus 
muscles,  find  the  artery,  clear  it,  and  pass  the  needle  from 
the  inner  side.  Jacobson  tells  us  to  remember  that  the 
phrenic  nerve  Hes  on  the  scalene  muscle,  the  pleura  is  inter- 
nal, the  internal  jugular,  inferior  thyroid,  and  vertebral  veins 
are  over  the  vessel,  and  the  thoracic  duct  on  the  left  side 
crosses  it  from  within  outward. 

The  Inferior  Thyroid  Artery. — Anatomy. — The  infe- 
rior thyroid  is  a  branch  of  the  thyroid  axis.  It  ascends  the 
neck,  passes  back  of  the  carotid  sheath  and  the  sympathetic 
nerve,  and  reaches  the  thyroid  gland.  The  recurrent  laryn- 
geal nerve  lies  behind  the  artery.  The  phrenic  nerve  is 
external  to  the  artery  and  near  to  it  in  the  first  part  of  its 
course  (up  to  the  point  of  origin  of  the  ascending  cervical 
branch).  The  ascending  cervical  branch  takes  origin  just 
before  the  artery  begins  to  dip  behind  the  carotid.  In  front 
of  the  beginning  of  the  left  artery  the  thoracic  duct  crosses. 
The  artery  is  ligated  in  the  second  part  of  its  course  (between 
its  distribution  and  the  origin  of  the  above-named  branch). 

Ligation. — Position  of  patient  and  incision  as  for  common 
carotid  in  triangle  of  necessity  (p.  294).  After  exposing  the 
sternocleidomastoid  retract  it  outward,  and  then  retract 
outward  the  carotid  artery  and  also  the  internal  jugular 
vein.  The  artery  will  be  found  a  little  below  the  carotid 
tubercle.  It  is  cleared  and  ligated.  Treves  advises  ligation 
close  to  the  level  of  the  carotid,  so  as  to  avoid  the  recurrent 
laryngeal  nerve. 

Innominate   Artery.  —  First    successfully    ligated    by 


DISEASES  AND   INJURIES    OF  HEART  AND    VESSELS.     29 1 

Smyth  of  New  Orleans.  It  is  an  almost  certainly  fatal 
operation. 

Anatomy. — The  innominate  artery  arises  from  the  begin- 
ning of  the  transverse  portion  of  the  arch  of  the  aorta,  passes 
to  the  back  of  the  right  sternoclavicular  joint,  and  divides 
into  the  common  carotid  and  subclavian.  It  rests  upon  the 
trachea.  It  has  upon  its  outer  side  the  pleura,  the  right 
innominate  vein,  and  the  pneumogastric  nerve.  Upon  its 
inner  side  the  remnant  of  the  thymus  and  the  beginning  of 
the  left  carotid  artery.  In  front  of  it  are  the  inferior  thyroid 
veins  of  the  right  side,  the  left  innominate  vein,  the  sterno- 
hyoid and  sternothyroid  muscles,  the  remnant  of  the  thymus 
gland,  and  sometimes  a  branch  from  the  right  pneumogastric 
nerve. 

Ligation. — Patient  supine,  shoulders  a  little  raised,  and 
head  thrown  back.  An  incision  from  the  upper  margin  of 
the  sternum  three  inches  in  length  along  the  anterior  mar- 
gin of  the  sternomastoid.  Another  cut  of  the  same  length 
is  made  along  the  upper  border  of  the  clavicle  to  meet  the 
first  cut.  Dissect  up  the  flap  of  skin  and  fascia.  Divide  the 
sternal  origin  and  a  part  of  the  clavicular  portion  of  the 
sternocleido,  and  cut  the  sternohyoid  and  sternothyroid 
just  above  their  sternal  origins  (Joseph  Bell).  Retract  the 
inferior  thyroid  veins.  Divide  the  dense  leaflet  of  cervical 
fascia.  Find  the  common  carotid,  and  trace  back  along  this 
vessel  until  the  innominate  comes  into  view.  Retract  the 
left  innominate  vein  downward.  The  needle  is  passed  from 
without  inward  to  avoid  the  right  innominate  vein  and  right 
pneumogastric.  If  the  needle  is  kept  close  to  the  artery, 
the  pleura  and  trachea  will  not  be  injured.' 

Region  of  the  Neck. — Anatomy. — The  side  of  the  neck 
is  that  space  between  the  median  line  in  front  and  the  ante- 
rior edge  of  the  trapezius  behind,  which  space  is  limited  be- 
low by  the  clavicle  and  above  by  the  body  of  the  jaw  and 
an  imaginary  line  running  from  the  angle  of  the  jaw  to  the 
mastoid  process.  The  sternocleidomastoid  muscle  divides 
this  space  into  an  anterior  and  a  posterior  triangle,  and  each 
of  the  triangles  is  subdivided  by  other  structures,  the  ante- 
rior into  four  spaces  and  the  posterior  into  two  (Fig.  61). 

Anterior  Triangle. — The  anterior  triangle  is  bounded  in 
front  by  the  median  line  of  the  neck,  behind  by  the  anterior 
margin  of  the  sternocleidomastoid,  and  above  by  the  body 
of  the  lower  jaw  and  an   imaginary  line  from  the  angle  of 

^  See  the  exceedingly  clear  and  terse  account  in  that  excellent  book,  A  Man- 
ual of  Su7-gical  Operations,  by  Joseph  Bell. 


292 


MODERN  SURGERY. 


Lower  jaw. 


the  jaw  to  the  mastoid  process.  This  space  is  subdivided 
into  four  smaller  triangles,  namely,  the  inferior  carotid,  the 
superior  carotid,  the  submaxillary,  and  the  submental. 

The  inferior'  carotid  triangle  is  called  the  "  triangle  of 
necessity,"  because  the  common  carotid  in  it  is  ligated,  not 

from  choice,  but  through  force  of 
necessity.  It  is  bounded  in  front 
by  the  median  line,  above  by  the 
anterior  belly  of  the  omohyoid  and 
the  hyoid  bone,  and  below  by  the 
anterior  edge  of  the  sternomastoid. 
The  floor  of  this  triangle  is  com- 
posed of  the  longus  colli,  the  sca- 
lenus anticus,  the  rectus  capitis  an- 
ticus  major  muscles,  the  sterno- 
hyoid and  sternothyroid  muscles. 
The  superior  carotid  triangle  is 
known  as  the  "  triangle  of  elec- 
tion," because,  whenever  possible, 
it  is  elected  to  tie  the  carotid  in 
this  situation.  In  this  region  the 
carotid  is  superficial,  and  there  can 
be  tied  either  the  external,  the  in- 
ternal, or  the  common  carotid,  as 
may  be  desired.  The  triangle  is 
bounded  behind  by  the  anterior 
edge  of  the  sternomastoid,  above  by  the  posterior  belly  of 
the  digastric,  and  below  by  the  anterior  belly  of  the  omo- 
hyoid. Its  floor  is  composed  of  the  inferior  and  middle 
constrictors  of  the  pharynx  and  the  thyrohyoid  and  hyo- 
glossus  muscles. 

The  siibmaxillary  triangle  is  bounded  above  by  the  body 
of  the  jaw  and  an  imaginary  line  from  the  angle  of  the  jaw 
to  the  mastoid  process,  behind  by  the  posterior  belly  of  the 
digastric  and  the  stylohyoid  muscle,  and  in  front  by  the 
anterior  belly  of  the  digastric.  Its  floor  is  composed  of  the 
mylohyoid  and  hyoglossus  muscles. 

The  submental  triangle  is  bounded  on  either  side  by  the 
anterior  belly  of  one  digastric  muscle ;  its  base  is  the  hyoid 
bone  and  its  floor  is  the  mylohyoid  muscle. 

The  posterior  triangle  is  bounded  in  front  by  the  posterior 
border  of  the  sternomastoid,  behind  by  the  anterior  edge  of 
the  trapezius,  and  below  by  the  clavicle.  The  posterior  belly 
of  the  omohyoid  subdivides  it  into  two  smaller  spaces,  the 
occipital  and  subclavian  triangles. 


Clavicle. 


Fig.  61. — The  triangles  of  the 
neck,  right-sided  view  (after  Keen)  : 
I.  Submaxillary  triangle  ;  2.  Triangle 
of  election,  or  superior  carotid  tri- 
angle;  3.  Submental  triangle;  4. 
Triangle  of  necessity,  or  inferior 
carotid  triangle ;  5.  Occipital  trian- 
gle ;  6.  Subclavian  triangle ;  7.  Hy- 
oid bone. 


D/SEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     293 

The  subclavian  triangle  is  bounded  above  by  the  posterior 
belly  of  the  omohyoid,  below  by  the  clavicle,  and  in  front 
by  the  posterior  border  of  the  sternomastoid.  Its  floor  is 
formed  by  the  first  rib  and  the  first  serration  of  the  serratus 
magnus  muscle. 

The  occipital  triangle  is  bounded  in  front  by  the  posterior 
edge  of  the  sternomastoid,  behind  by  the  anterior  border 
of  the  trapezius,  and  below  by  the  posterior  belly  of  the 
omohyoid  muscle. 

Common  Carotid  Artery. — The  line  of  the  common 
carotid  artery  is  from  the  sternoclavicular  articulation  to 
midway  between  the  angle  of  the  jaw  and  the  mastoid 
process,  the  head  being  turned  toward  the  opposite  side. 

Anatomy  (PI.  3,  Fig.  3). — The  right  common  carotid 
arises  from  the  innominate  opposite  the  sternoclavicular 
joint ;  the  left  common  carotid  arises  from  the  arch  of 
the  aorta.  In  the  neck  the  two  carotids  possess  identical 
relations.  The  common  carotid  runs  upward  and  outward 
from  behind  the  sternoclavicular  articulation  to  a  level 
with  the  upper  border  of  the  thyroid  cartilage,  at  which 
point  it  divides  into  the  external  and  internal  carotid.  The 
common  carotid  is  contained  in  a  sheath  from  the  cervical 
fascia,  which  sheath  also  holds,  though  in  separate  compart- 
ments, the  internal  jugular  vein  on  the  outer  side  of  the 
artery  and  the  pneumogastric  nerve  between  the  vein  and 
artery  and  behind  them.  The  anterior  edge  of  the  sterno- 
mastoid muscle  lies  over  the  artery  and  is  a  guide.  Low  in 
the  neck  the  common  carotid  is  deep,  being  covered  by  skin, 
superficial  fascia,  platysma,  deep  fascia,  and  the  sternomas- 
toid, sternohyoid,  and  sternothyroid  muscles.  Above  the 
omohyoid  the  vessel  is  more  superficial,  being  covered  by 
the  skin,  superficial  fascia,  platysma,  deep  fascia,  and  the  an- 
terior edge  of  the  sternomastoid.  Upon  the  sheath  (occa- 
sionally within  it),  above  the  crossing  of  the  omohyoid 
muscle,  lies  the  descendens  noni  nerve — the  descending 
branch  of  the  ninth  pair  of  Willis  (the  hypoglossal).  This 
nerve  is  a  valuable  guide  to  the  sheath  in  the  triangle  of 
election. 

The  sternomastoid  branch  of  the  superior  thyroid  artery 
crosses  the  carotid  a  little  below  its  bifurcation,  and  the  supe- 
rior thyroid  veins  cross  it  in  this  region  ;  the  middle  thyroid 
vein  crosses  the  middle  of  the  line  of  the  artery,  and  the  an- 
terior jugular  vein  crosses  low  down.  The  carotid  rests  upon 
the  longus  colli  and  rectus  capitis  anticus  major  muscles,  the 
sympathetic  nerve  lying  between  the  last-named  muscle  and 


294  MODERN  SURGERY. 

the  vessel,  outside  the  carotid  sheath.  The  recurrent  laryn- 
geal nerve  passes  behind  the  carotid  below  the  omohyoid 
muscle,  and  the  inferior  thyroid  artery  passes  behind  the 
carotid  just  above  the  omohyoid  muscle.  The  carotid  is  in 
relation  internally  with  the  trachea,  thyroid  gland,  larynx, 
and  pharynx.  On  its  outer  side  are  the  pneumogastric  nerve 
(which  is  on  a  posterior  plane)  and  the  internal  jugular  vein. 
On  the  left  side,  low  down  in  the  neck,  the  jugular  vein  often 
lies  in  front,  or  partly  in  front,  of  the  artery.  Ligation  of  the 
common  carotid  was  first  successfully  performed  in  1806  by 
Sir  Astley  Cooper. 

Ligation  in  the  Triangle  of  Necessity. — In  this  operation  the 
position  is  supine  with  the  shoulders  raised,  a  sand  pillow  un- 
der the  neck,  and  the  head  turned  to  the  opposite  side  with 
the  chin  raised.  The  operator  stands  upon  the  side  operated 
upon.  The  incision,  three  inches  long,  at  an  angle  of  five 
degrees  to  the  arterial  line,  runs  from  the  level  of  the  cricoid 
cartilage  downward  and  inward  toward  the  sternoclavicular 
joint,  following  the  inner  border  of  the  sternocleidomastoid. 
Open  the  deep  fascia,  draw  the  sternocleidomastoid  outward, 
retract  the  sternohyoid  and  sternothyroid  muscles  inward, 
and  feel  for  the  carotid  tubercle  of  Chassaignac.  This  tuber- 
cle is  the  costal  process  of  the  sixth  cervical  vertebra,  and 
lies  directly  under  the  artery.  The  tubercle  is  found  about 
the  point  at  which  the  omohyoid  crosses  the  carotid.  When 
the  tubercle  is  found  we  know  the  situation  of  the  artery,  and 
that  the  triangle  of  necessity  is  below,  and  the  triangle  of 
election  above,  the  tubercle.  Pull  the  omohyoid  muscle  up- 
ward. Open  the  sheath  of  the  artery  on  its  inner  side,  clear 
it,  and  pass  the  needle  from  without  inward  to  avoid  the  in- 
ternal jugular  vein,  remembering  that  the  pneumogastric 
nerve  is  in  the  same  sheath  as  the  artery  and  vein,  pos- 
terior and  external  to  the  artery.  In  this  operation  the  in- 
ferior thyroid  veins  are  much  in  the  way,  the  anterior  jugular 
vein  crosses  low  down,  and  on  the  left  side,  at  the  root  of  the 
neck,  the  internal  jugular  vein  may  be  in  front  of  the  carotid 
artery.  If  the  incision  is  not  sufficiently  wide,  divide  the 
sternocleidomastoid  or  the  sternohyoid  and  thyroid  muscles. 
In  the  triangle  of  necessity  the  descendens  noni  nerve  does 
not  serve  as  a  guide  to  the  sheath.     (See  PI.  3,  Fig.  4.) 

Ligation  in  the  Triangle  of  Election. — The  position  for  this 
operation  is  the  same  as  in  the  preceding  one.  An  incision, 
three  inches  in  length,  is  made  along  the  anterior  edge  of  the 
sternomastoid  in  the  line  of  the  artery,  the  middle  of  this  in- 
cision being  opposite  the  cricoid  cartilage.     In  cutting  the 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     295 

superficial  fascia,  avoid  the  external  jugular  vein,  the  course 
of  which  should  be  outlined  before  making  the  incision.  The 
line  of  the  external  jugular  is  from  the  angle  of  the  jaw  to  the 
middle  of  the  clavicle.  Open  the  deep  fascia,  retract  the 
sternocleidomastoid  outward,  feel  for  the  carotid  tubercle, 
draw  the  omohyoid  downward,  find  the  descendens  noni 
nerve  upon  the  sheath,  open  the  sheath  at  its  inner  side,  and 
pass  the  needle  from  without  inward.  This  incision  permits 
ligation  of  either  the  superior  thyroid  or  the  external,  inter- 
nal, or  common  carotid,  and  if  it  be  extended  up  a  little,  there 
can  be  tied  through  it,  the  lingual,  and  even  the  facial  and 
occipital,  arteries.     (See  PI.  3,  Fig.  4.) 

Kxternal  Carotid  Artery. — The  li/ie  of  the  external 
carotid  artery  is  the  upper  portion  of  the  common  carotid 
line. 

Anatomy  (PI.  3,  Fig.  3). — The  external  carotid  artery, 
which  is  one  of  the  terminal  branches  of  the  common  carotid, 
arises  on  a  level  with  the  upper  border  of  the  thyroid  cartilage 
and  runs  to  the  level  of  the  neck  of  the  condyle  of  the  lower 
jaw.  At  its  point  of  origin  it  is  covered  only  by  skin,  platysma 
and  fascia,  and  the  edge  of  the  sternomastoid,  but  as  it  ascends 
it  passes  beneath  the  digastric  and  stylohyoid  muscles  and 
into  the  parotid  gland.  The  glossopharyngeal  nerve,  styloid 
process,  and  stylophaiyngeus  muscle  lie  between  the  external 
and  internal  carotid  arteries.  The  hypoglossal  nerve  crosses 
the  vessel  just  below^  the  digastric  muscle,  and  the  facial  and 
lingual  veins  cross  it  a  little  below  the  nerve.  The  first 
branch  is  the  superior  thyroid,  which  arises  from  the  veiy 
beginning  of  the  trunk.  The  lingual  arises  on  a  level  with 
the  greater  cornu  of  the  hyoid  bone.  The  facial  and  occipital 
take  origin  above  the  lingual.  Each  of  them  can  be  ligated 
through  the  incision  of  this  operation. 

Operation. — The  position  is  the  same  as  that  for  ligation 
of  the  common  carotid.  The  point  of  election  is  between 
the  superior  thyroid  and  the  lingual.  Make  an  incision  three 
inches  long  in  the  arterial  line,  from  near  the  angle  of  the  jaw 
to  opposite  the  middle  of  the  th}Toid  cartilage,  cut  through 
the  skin,  superficial  fascia,  platysma,  and  deep  fascia,  and 
retract  the  sternocleidomastoid  outward.  Look  for  the 
digastric  muscle,  find  the  hypoglossal  nerve,  and  feel  for 
the  greater  cornu  of  the  hyoid  bone.  Open  the  sheath  a 
little  below  the  hyoid  cornu  and  pass  the  needle  from  with- 
out inw^ard.  Ligation  of  the  external  carotid  has  been  ne- 
glected because  ligation  of  the  common  carotid  is  easier. 

Internal    Carotid   Artery. — The   line-   of  the    internal 


296  MODERN  SURGER  V. 

carotid  is  parallel  with  and  half  an  inch  external  to  the 
line  for  the  external  carotid. 

Anatomy  (PL  3,  Fig.  3). — The  internal  carotid  artery,  the 
other  terminal  branch  of  the  common  carotid,  arises  on  a  level 
with  the  upper  border  of  the  thyroid  cartilage  and  enters  the 
carotid  canal.  The  first  inch  of  the  artery  is  the  only  point 
where  a  ligature  is  ever  applied,  this  point  being  covered  only 
by  skin,  platysma,  fascia,  and  the  sternomastoid ;  higher  up  it 
is  more  deeply  placed.  It  rests  upon  the  vertebrae  and  the 
rectus  capitis  anticus  major  muscle.  The  internal  jugular 
vein  is  in  the  same  sheath  and  exte^-nal  to  the  artery ;  the 
pneumogastric  is  in  the  same  sheath,  between  the  artery 
and  the  vein,  but  posterior  to  both.  The  superior  cervical 
ganglion  of  the  sympathetic  lies  behind  the  origin  of  the 
internal  carotid,  and  between  the  ganglion  and  the  artery 
is  the   superior  laryngeal  nerve. 

Operation. — In  this  operation  the  position  is  the  same  as  in 
ligation  of  the  external  carotid.  Incision  as  for  the  external 
carotid,  except  that  it  is  half  an  inch  external.  The  sterno- 
cleido-mastoid  is  drawn  outward,  the  external  carotid  artery 
is  found  and  drawn  inward,  the  internal  carotid  is  found  and 
drawn  outward,  and  the  needle  is  passed  from  without  inward. 
The  internal  carotid  is  known  by  its  more  external  position 
and  by  the  fact  that  it  gives  off  no  branches. 

Superior  Thyroid  Artery  (PL  3,  Fig.  3). — This  branches 
off  from  the  external  carotid  below  the  level  of  the  greater 
cornu  of  the  hyoid  bone,  in  the  triangle  of  election.  It  is  at 
first  superficial,  runs  first  upward  and  inward,  next  downward 
and  forward,  passes  underneath  the  omohyoid,  sternohyoid, 
and  sternothyroid  muscles,  and  reaches  the  thyroid  gland. 

Ligation. — Same  position  of  patient  and  surgeon  as  in 
carotid  ligation.  May  be  reached  through  incision  employed 
in  ligation  of  external  carotid.  Gross  employed  an  incision 
starting  at  the  edge  of  the  hyoid  bone,  and  running  down- 
ward and  outward  to  the  sternomastoid  muscle.  Cut  the 
skin,  superficial  and  deep  fascia,  and  find  the  artery  deeply 
placed  in  the  triangle  of  election  between  the  carotid  sheath 
and  the  thyroid  gland. 

I/imgual  Artery. — Anatomy  (PL  3,  Fig.  3). — The  lingual 
artery  arises  from  the  external  carotid  opposite  the  greater 
cornu  of  the  hyoid  bone,  passes  beneath  the  digastric  and 
stylohyoid  muscles,  reaches  the  margin  of  the  hyoglossus, 
passes  under  that  muscle,  and  emerges  from  under  it  to  run 
along  the  under  surface  of  the  tongue.  The  place  of  elec- 
tion for  ligation  is  where  the  artery  is  beneath  the  hyoglossus 


DISEASES  AND    INJURIES   OF  HEART  AND    VESSELS.     297 

muscle  and  rests  upon  the  genio<^lossus.  Its  guide  is  the 
hypoglossal  nerve,  which  lies  upon  the  muscle,  but  at  a 
slightly  higher  level  than  the  artery. 

Operation. — In  this  operation  the  position  of  the  patient 
is  recumbent  with  the  shoulders  raised  and  the  face  turned 
away  from  the  side  to  be  operated  upon.  The  surgeon 
should  stand  upon  the  affected  side.  A  curved  incision  is 
made  from  a  little  external  to  the  symphysis  of  the  lower 
jaw,  downward  and  outward,  to  just  above  the  greater  cornu 
of  the  hyoid  bone,  and  upward  and  outward  to  just  in  front 
of  the  facial  artery  at  the  lower  edge  of  the  lower  jaw.  Incise 
the  skin,  the  superficial  fascia  and  platysma,  and  the  deep 
fascia.  Clear  the  submaxillary  gland  and  retract  it  well  up- 
ward. Divide  the  fascia  below  the  gland  by  a  transverse  in- 
cision. Find  the  posterior  edge  of  the  mylohyoid  and  the 
bellies  of  the  digastric.  Catch  one  of  the  digastric  tendons 
and  have  it  hooked  down  and  out  (Treves).  Clear  the  hyo- 
glossus  muscle  with  a  dissector ;  find  the  hypoglossal  nerve 
and  ranine  vein  and  draw  them  a  little  upward.  Divide  the 
hyoglossus  muscle  transversely  a  little  above  the  hyoid  bone 
and  below  the  level  of  the  hypoglossal  nerve,  find  the  artery, 
and  pass  the  needle  from  above  downward. 

Facial  Artery. — Anatomy  (PI.  3,  Fig.  3). — Arises  from 
the  external  carotid  a  little  above  the  lingual,  runs  upward  and 
forward  beneath  the  body  of  the  inferior  maxillary  bone, 
passes  along  a  groove  in  the  posterior  and  upper  surface  of 
the  submaxillary  gland,  crosses  the  body  of  the  lower  jaw  at 
the  lower  anterior  edge  of  the  masseter  muscle,  and  passes  for- 
ward and  upward  to  the  angle  of  the  mouth  and  side  of  the  nose. 

Ligation  (PI.  3,  Fig.  4). — Is  rarely  ligated  in  the  cervical 
portion,  but  may  be  reached  through  the  incision  employed 
for  ligation  of  the  external  carotid.  The  vessel  may  be  tied 
before  it  crosses  the  submaxillary  gland,  the  styloyhoid  and 
digastric  muscles  being  drawn  up.  The  vessel  is  reached  in 
the  facial  portion  of  its  course  by  a  one-inch  cut  at  the  an- 
terior edge  of  the  masseter  muscle.  Branches  of  the  facial 
nerve  are  pushed  aside.  The  needle  is  passed  from  behind 
forward  to  avoid  the  vein  (Jacobson). 

Temporal  Artery. — The  line  of  the  temporal  artery 
passes  "  upward  over  the  root  of  the  zygoma,  midway  be- 
tween the  condyle  of  the  jaw  and  the  tragus  "  (Jacobson). 

Anatomy. — Arises  from  the  external  carotid  behind  the 
condyle  of  the  jaw  and  in  the  parotid  gland,  passes  over  the 
zygoma  and  divides  into  two  terminal  branches. 

Ligation. — Patient  recumbent  and  head  turned  to  opposite 


298  MODERN  SURGERY. 

side.  An  incision  an  inch  in  length  is  made,  the  superficial 
structures  and  dense  fascia  are  divided,  the  vein  is  retracted 
backward,  and  the  needle  is  passed  from  behind  forward. 

Occipital  Artery. — Takes  origin  from  the  posterior  sur- 
face of  the  external  carotid,  below  the  digastric  muscle  and 
opposite  the  point  of  origin  of  the  facial  artery.  It  ascends 
beneath  the  digastric  and  stylohyoid  muscles  and  parotid 
gland;  the  hypoglossal  nerve  hooks  around  it  from  behind 
forward.  It  crosses  the  internal  carotid  artery,  the  internal 
jugular  vein,  the  pneumogastric  and  spinal  accessory  nerves  ; 
passes  between  the  mastoid  process  of  the  temporal  bone  and 
the  atlas ;  grooves  the  temporal  bones ;  penetrates  the  trape- 
zius and  ascends  over  the  occiput. 

Ligation. — We  can  ligate  low  down  through  the  same 
incision  as  is  employed  to  reach  the  external  carotid.  The 
hypoglossal  nerve  is  avoided.  To  tie  back  of  the  mastoid 
process  employ  the  same  position  as  in  ligation  of  carotid. 
Carry  an  incision  from  the  tip  of  the  mastoid  upward  and 
backward,  reaching  a  point  midway  between  the  mastoid 
and  the  occipital  protuberance  (Jacobson).  Cut  the  skin, 
the  fascia,  the  sternocleidomastoid,  the  splenius  capitis  and 
possibly  a  portion  of  the  trachelomastoid.  Bring  the  head 
toward  the  operator  to  relax  the  structures,  retract  the 
edges,  and  clear  the  artery  where  it  lies  between  the  mas- 
toid and  the  transverse  process  of  the  atlas  (Jacobson).  An 
electric  forehead  light  is  of  great  assistance  in  finding  the 
vessel.  Pass  the  needle  away  from  the  vein  or  veins  (there 
are  often  several). 

Dorsalis  Pedis  Artery. — The  line  of  the  dorsalis  pedis 
artery  is  from  the  middle  of  the  front  of  the  ankle-joint  to 
the  middle  of  the  base  of  the  first  interosseous  space. 

Anatomy  (PI.  4,  Fig.  i). — The  dorsalis  pedis  is  a  continua- 
tion of  the  anterior  tibial  arteiy,  and  it  runs  from  the  bend  of 
the  ankle  to  the  proximal  extremity  of  the  first  interosseous 
space,  where  it  divides  into  the  dorsalis  hallucis  and  the  com- 
municating arteries.  The  artery  rests,  from  above  downward, 
upon  the  astragalus,  scaphoid,  and  internal  cuneiform  bones, 
and  at  its  point  of  bifurcation  lies  between  the  heads  of  the 
first  dorsal  interosseous  muscle.  It  may  lie  in  some  persons 
a  little  external  to  this  course.  It  is  held  upon  the  bones  by 
a  distinct  layer  derived  from  the  deep  fascia.  This  artery  is 
covered  by  skin,  by  superficial  and  deep  fascia,  and  by  the 
annular  ligament  above,  and  is  sometimes  partly  overlaid  by 
the  extensor  proprius  pollicis  muscle,  and  is  crossed,  just  be- 
fore its  bifurcation,  by  the  innermost  tendon  of  the  extensor 


LIGATIONS. 


Plate  4. 


■**Vi.>ij|^^jj^^ 


■2    S 


<  < 


DISEASES  AND   IXJURIES   OF  HEART  AND    VESSELS.     299 

brevis  muscle.  The  inner  tendon  of  the  extensor  longus 
digitorum  is  to  the  outer  side  of  the  vessel ;  the  tendon  of  the 
extensor  proprius  pollicis  is  to  the  inner  side,  and  is  a  guide. 
The  artery  is  ligated  in  the  dorsal  triangle  of  the  foot — a 
space  which  is  bounded  abov^e  by  the  lower  edge  of  the  an- 
nular ligament,  externally  by  the  inner  tendon  of  the  extensor 
brevis,  and  internally  by  the  tendon  of  the  extensor  proprius 
pollicis.  The  artery  has  venae  comites ;  the  anterior  tibial 
nerve  lies,  as  a  rule,  to  its  inner  side,  but  may  be  found  upon 
the  artery  or  to  its  outer  side,  and  the  inner  division  of  the 
musculocutaneous  nerve  is  external  to  the  vessel  in  the 
superficial  parts. 

Operation  (PI.  4,  Fig.  2). — In  this  operation  the  position  of 
the  patient  is  supine  with  the  legs  and  feet  extended.  Heath 
flexes  the  leg  partly  and  rests  the  sole  of  the  foot  directly 
upon  the  table.  The  surgeon  stands  below  the  extremity, 
cutting  from  above  downward.  Make  an  incision  two  inches 
in  length  along  the  arterial  line,  beginning  opposite  the  lower 
edge  of  the  annular  ligament  and  running  along  by  the  tendon 
of  the  extensor  proprius  pollicis;  cut  through  the  skin  and 
superficial  and  deep  fascia ;  have  the  toes  extended ;  retract 
the  tendon  of  the  extensor  proprius  pollicis  inward,  and  the 
tendon  of  the  extensor  longus  outward ;  clear  the  artery, 
find  the  nerve,  try  to  separate  the  venae  comites,  and  pass 
the  needle  from  the  nerve. 

Anterior  Tibial  Artery. — To  locate  the  line  of  the 
anterior  tibial,  find  a  point  midway  between  the  head  of 
the  fibula  and  the  tuberosity  of  the  tibia,  drop  one  inch,  and 
draw  a  line  from  the  second  point  to  the  middle  of  the  front 
of  the  ankle-joint. 

Anatomy. — The  anterior  tibial  artery  is  one  of  the  termi- 
nal branches  of  the  popliteal.  It  arises  opposite  the  lower 
border  of  the  popliteus  muscle,  passes  forward  between  the 
two  heads  of  the  posterior  tibial  muscle,  comes  to  the  front 
of  the  leg  through  an  opening  in  the  interosseous  mem- 
brane, and  runs  down  to  the  middle  of  the  front  of  the 
ankle-joint.  In  the  upper  two-thirds  of  its  course  it  rests 
upon  the  interosseous  membrane,  to  which  it  is  fastened  by 
firm  fascia ;  in  the  lower  third  it  lies  first  upon  the  front  of 
the  tibia  and  then  upon  the  anterior  ligament  of  the  ankle- 
joint.  For  its  upper  two-thirds  the  artery  has  the  tibialis 
anticus  muscle  just  internal  to  it;  at  the  junction  of  the 
middle  and  lower  thirds  the  extensor  proprius  pollicis  comes 
from  the  outside  and  lies  either  upon  the  artery  or  to  its 
inner  side  for  the  rest  of  its  course.     Externally  in  its  upper 


300  MODERN  SURGERY. 

third  is  the  extensor  longus  digitorum,  in  the  middle  third 
is  the  extensor  proprius  polhcis ;  in  the  lower  third,  the 
proprius  pollicis,  having  crossed  to  the  inner  side,  the  ex- 
tensor communis  digitorum  again  becomes  the  outer  boun- 
dary. The  artery  is  covered  by  skin  and  by  superficial  and 
deep  fascia.  In  its  upper  third  it  is  deeply  set  between  the 
muscles  ;  in  its  middle  third  it  is  less  overlaid  by  muscle ;  in 
its  lower  third  it  is  superficial  except  where  it  is  crossed  by 
the  extensor  proprius  and  where  it  is  covered  by  the  annular 
ligament.  The  artery  has  venae  comites.  In  the  lower  three- 
fourths  of  its  course  it  is  accompanied  by  the  anterior  tibial 
nerve,  which  in  its  course  in  the  upper  third  of  the  leg  is 
external  to  the  artery ;  in  the  middle  third  it  is  external  and 
a  little  in  front  of  the  artery ;  and  in  the  lower  third  it  is  ex- 
ternal to  or  upon  the  artery  (PI.  3,  Fig.  5). 

Operations. — The  ligations  of  the  anterior  tibial  (PI.  3, 
Fig.  6)  are  (i)  in  the  lower  third;  (2)  in  the  middle  third; 
and  (3)  in  the  upper  third.  In  all  these  ligations  the  sur- 
geon stands  outside  of  the  extremity,  cutting  from  above 
downward  on  the  right  side  and  from  below  upward  on  the 
left  side. 

Ligation  in  the  Lower  Third. — The  surgeon  stands  to  the 
outside  of  the  extremity,  cutting  from  above  downward  upon 
the  right  leg  and  from  below  upward  on  the  left  leg.  Make 
an  incision  three  inches  long  in  the  line  of  the  artery  and 
over  the  annular  ligament.  This  incision  is  external  to  the 
tibialis  anticus  muscle  and  half  an  inch  from  the  outer  border 
of  the  tibia  (Barker).  Divide  the  skin  and  fascia,  retract  the 
tendon  of  the  tibialis  anticus  inward,  and  the  tendon  of  the 
extensor  proprius  polhcis  outward,  along  with  the  tendons 
of  the  extensor  longus.  Flex  the  ankle-joint  to  relax  the 
tendons,  and  clear  the  artery.  Draw  the  nerve  external  and 
pass  the  ligature  from  without  inward.  In  order  to  recog- 
nize the  muscles  in  this  as  in  other  ligations,  rely  largely 
upon  the  finger  while  the  muscles  are  being  moved. 

Ligation  in  the  Middle  Third. — In  this  operation  the  pro- 
cedure is  similar  to  the  above.  Remember  that  the  nerve 
lies  upon  the  vessel  and  that  the  extensor  proprius  pollicis 
muscle  is  external.  The  nerve  is  retracted  outward  and  the 
needle  is  passed  from  the  nerve.  A  good  rule  for  detecting 
the  artery  is  to  find  the  outer  edge  of  the  tibia  and  by  this 
locate  the  interosseous  membrane,  and  then,  by  passing  out 
along  this  membrane,  discover  the  artery. 

Ligation  in  the  Upper  Third. — In  this  operation  the  posi- 
tion is  the  same  as  in  the  above.     Make  an  incision  three 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     30I 

inches  long  in  the  arterial  line.  On  opening  the  deep  fascia, 
do  not  rely  on  the  eye  for  finding  the  muscular  interspace, 
as  often  the  latter  cannot  be  seen,  and  neither  a  white  nor  a 
yellow  line  is  reliable.  Place  the  index  finger  deep  in  the 
wound  and  have  the  tibialis  anticus  and  extensor  longus 
muscles  successively  rendered  tense  by  an  assistant.  In 
opening  the  interspace  use  the  handle  of  the  knife.  Relax 
the  muscles,  retract  the  tibialis  anticus  inward,  and  draw 
the  extensor  longus  outward.  Find  the  interosseous  mem- 
brane where  it  is  attached  to  the  edge  of  the  tibia,  and  the 
artery  will  be  found  upon  this  membrane,  between  the  tibia 
and  the  nerve.  Clear  the  vessel  and  pass  the  ligature  from 
without  inward  to  avoid  the  nerve. 

Posterior  Tibial  Artery. — The  line  of  the  posterior 
tibial  is  from  the  middle  of  the  popliteal  space  to  a  point 
midway  between  the  tip  of  the  inner  malleolus  and  the  point 
of  the  heel  (PI.  4,  Figs.  5,  6). 

Anatomy. — The  posterior  tibial  is  the  larger  of  the  two 
terminal  branches  of  the  popliteal.  It  arises  opposite  the 
lower  border  of  the  popliteus  muscle,  runs  down  between 
the  deep  and  superficial  flexor  muscles  to  midway  between 
the  tip  of  the  malleolus  and  the  point  of  the  heel,  and 
divides  into  the  external  and  internal  plantar  vessels.  In  its 
upper  third  it  is  very  deep  and  midway  between  the  tibia  and 
fibula;  in  its  middle  third  it  is  less  deep,  having  passed  inward; 
and  in  its  lower  third  it  is  superficial.  At  the  ankle  the 
artery  is  beneath  the  annular  ligament.  From  above  down- 
ward the  posterior  tibial  artery  rests  upon  the  posterior  tibial 
muscle,  the  flexor  longus  digitorum  muscle,  the  posterior 
surface  of  the  tibia,  and  the  internal  lateral  ligament  of  the 
ankle-joint.  For  the  first  inch  or  two  of  the  course  of  the 
artery  the  posterior  tibial  nerve  is  internal ;  the  nerve  then 
crosses  to  the  outer  side,  and  remains  on  that  side  through- 
out the  rest  of  its  course.  When  the  knee  is  partly  flexed 
and  the  leg  is  laid  upon  its  outer  surface  the  artery  is  be- 
tween the  operator  and  the  nerve,  and  the  nerve  is  between 
the  artery  and  the  table.  Back  of  the  malleolus,  in  the  first 
compartment,  lies  the  posterior  tibial  muscle ;  in  the  next 
compartment  is  the  flexor  longus  digitorum  muscle ;  in  the 
next  are  the  artery  and  nerve ;  and  in  the  most  posterior  is 
the  flexor  longus  pollicis  muscle. 

Operations. — Ligation  back  of  the  Malleolus. — In  this  ope- 
ration the  position  of  the  patient  is  recumbent  with  the  thigh 
abducted  and  the  leg  flexed  and  resting  upon  its  outer  sur- 
face.    The  surgeon  stands  to  the  outside.     Make  a  two-inch 


302  MODERN  SURGERY. 

semilunar  incision  corresponding  in  its  curve  to  the  malle- 
olus and  half  an  inch  posterior  to  its  margin.  Cut  down 
to  the  annular  ligament,  incise  it,  and  find  the  artery  and 
venae  comites.  Clear  the  vessel  and  pass  the  needle  from 
behind  forward  (to  avoid  the  nerve,  which  is  here  posterior 
and  external).  Do  not  make  the  preliminary  incision  nearer 
the  malleolus  than  half  an  inch,  as  the  sheath  of  the  tibialis 
posticus  muscle  would  then  surely  be  opened.  In  sewing 
up,  suture  the  ligament  by  buried  sutures  (PI.  4,  Fig.  6). 

Ligation  in  the  Middle  of  the  Leg. — In  this  operation  the 
position  is  the  same  as  in  the  abo\^e.  Feel  for  the  inner 
border  of  the  tibia,  and  make  an  incision  four  inches  long 
one  inch  behind  the  osseous  border,  parallel  with  it,  and  ex- 
tending through  skin  and  superficial  and  deep  fascia.  Draw 
the  gastrocnemius  outward.  Incise  the  soleus,  but  not  the 
fascia  beneath  the  soleus ;  cut  this  fascia,  after  dropping  the 
handle  of  the  knife  so  that  the  blade  is  at  right  angles  with 
the  plane  of  the  tibia.  Clear  the  artery ;  pass  the  needle 
from  without  inward  (PI.  4,  Fig.  6). 

The  popliteal  artery  is  almost  never  ligated  in  con- 
tinuity. It  can  be  tied  at  the  upper  portion  of  the  popliteal 
space,  at  the  lower  portion  of  the  popliteal  space,  or  at  the 
inner  side  of  the  thigh. 

Anatomy  (Fig.  62). — The  popliteal  artery  is  the  continua- 
tion of  the  femoral,  and  runs  from  the  opening  in  the  adductor 
magnus  muscle  to  the  lower  margin  of  the  popliteus  muscle. 
This  vessel  runs  downward  and  outward  behind  the  knee- 
joint  and  in  the  popliteal  space.  The  ham  or  popliteal 
space  is  a  lozenge-shaped  space,  which  above  the  joint  is 
bounded  on  the  outside  by  the  biceps,  and  on  the  inside 
by  the  semitendinosus,  semimembranosus,  gracilis,  and  sar- 
torius  muscles,  while  below  the  joint  it  is  bounded  externally 
by  the  plantaris  and  outer  head  of  the  gastrocnemius  muscles, 
and  internally  by  the  inner  head  of  the  gastrocnemius  muscle. 
The  floor  of  this  space  is  formed  by  the  surface  of  the  femur, 
the  posterior  ligament  of  the  knee-joint,  the  end  of  the  tibia, 
and  the  popliteus  fascia.  The  internal  popliteal  nerve  runs 
down  the  middle  of  the  popliteal  space ;  it  is  superficial  to 
the  vessels,  in  the  upper  half  of  the  space  external  to  them, 
in  the  lower  half  internal  to  them.  The  external  popliteal 
nerve  is  in  the  outer  side  of  the  space.  The  popliteal  vein 
is  between  the  nerve  and  the  artery.  Above  the  knee-joint 
it  is  to  the  outside  of  the  artery,  but  below  the  knee-joint  it 
is  to  the  inner  side.     The  artery  lies  deeply  in  the  space. 

Ligation  in    Upper  Third. — Patient  prone.     The  surgeon 


DISEASES  AND   hXJURIES   OE  HEART  AND    VESSELS.     303 

Stands  on  the  outside  of  the  Hmb  and  makes  a  vertical  incision 
three  inches  in  length  along  the  outer  margin  of  the  semi- 
membranosus muscle,  exposes  the  popliteal  nerve,  retracts 
the  muscle  inward  and  the  nerve  outward,  exposes  the  artery, 


Fig.  62. — Anatomy  of  popliteal  artery  (Bernard 
and  Huette). 


Fig.  63. — Ligation  of  popliteal  artery  in 
its  upper  third  (Bernard  and  Huetie). 


separates  it  from  the  other  structures,  and  passes  the  needle 
from  without  inward  (Fig.  6-^. 

Ligation  in  Lozver  Tliii'd. — Make  a  three-inch  vertical 
incision  between  the  heads  of  the  gastrocnemius  muscle. 
Avoid  the  external  saphenous  vein  and  nerve,  and  retract 
them  with  the  popliteal  nerve.  Separate  the  artery  from  the 
vein  and  pass  the  needle  from  within  outward. 

Femoral  Artery. — The  line  of  the  femoral  artery  is 
from  midway  between  the  anterior  superior  spine  of  the 
ilium  and  the  symphysis  pubis  to  the  adductor  tubercle  on 
the  inner  condyle  of  the  femur,  the  thigh  being  abducted  and 
resting  upon  its  outer  surface  (PI.  4,  Fig.  3). 

Anatomy. — The  femoral  artery  is  the  continuation  of  the 
external  iliac  trunk ;  it  extends  from  the  lower  border  of 
Poupart's  ligament  to  the  opening  in  the  adductor  magnus 
muscle,  and  hence  occupies  the  upper  two-thirds  of  the 
thigh.  The  artery  for  its  first  five  inches  is  superficial,  lying 
in  Scarpa's  triangle,  a  space  which  is  bounded  externally  by 
the  sartorius  musc:le  and  internally  by  the  adductor  longus. 


304  MODERN  SURGERY. 

its  base  being  Poupart's  ligament  and  its  floor  being  com- 
posed of  the  psoas,  iliacus,  pectineus,  and  adductor  longus 
muscles,  and  often  the  adductor  brevis.  The  artery-  enters 
the  triangle  as  the  common  femoral,  but  after  a  two-inch 
course  it  divides  into  the  profunda  (which  passes  deeply), 
and  the  superficial  femoral.  The  latter  vessel  is  the  one 
alluded  to  in  this  section. 

At  the  base  of  Scarpa's  triangle  the  vein  is  internal,  the 
artery  is  between,  and  the  nerve  is  external  (v.  a.  x.j.  At 
the  apex  of  the  triangle  the  vein  is  internal  and  a  little  pos- 
terior. At  the  apex  of  the  triangle  the  superficial  femoral 
passes  under  the  sartorious  muscle  and  enters  into  Hunter's 
canal,  which  occupies  the  middle  third  of  the  thigh  and 
which  terminates  at  the  opening  by  the  adductor  magnus 
muscle.  Hunter's  canal  is  bounded  externally  by  the  vastus 
internus,  internally  by  the  adductors  longus  and  magnus,  and 
its  roof  is  fascia  which  stretches  from  the  adductor  longus  to 
the  vastus.  In  Hunter's  canal  the  vein  is  behind  the  artery 
in  the  upper  part,  but  external  to  it  in  the  lower  part,  and 
is  firmly  attached  to  the  artery.  There  may  be  two  veins. 
Inside  Hunter's  canal,  but  outside  the  femoral  sheath,  is 
the  long  saphenous  nerve,  which  crosses  the  arter>'  from 
without  inward. 

A  way  to  remember  the  relation  of  the  femoral  vein 
to  the  femoral  artery  is  to  recall  the  fact  that  the  relation 
of  the  vein  to  the  arteiy  is  always  contrary  to  the  relation 
of  the  sartorius  muscle  to  the  artery :  when  the  sartorius 
muscle  is  external  to  the  arter}^  the  vein  is  internal,  as  at  the 
base  of  Scarpa's  triangle  ;  when  the  sartorius  muscle  is  cross- 
ing in  front  toward  the  inside  of  the  artery  the  vein  is  pass- 
ing at  the  back  to  the  outside,  as  at  the  apex  of  Scarpa's 
triangle ;  when  the  muscle  is  over  the  artery  the  vein  is  back 
of  it.  as  in  the  upper  third  of  Hunter's  canal ;  and  when  the 
muscle  is  to  the  inside  of  the  artery  the  vein  is  to  the  out- 
side, as  in  the  lower  two-thirds  of  Hunter's  canal.  In  a 
ligation  at  the  apex  of  Scarpa's  triangle  the  inner  edge  of 
the  sartorius  is  the  guide.  In  a  ligation  in  Hunter's  canal 
the  long  saphenous  nerve  is  the  guide. 

Operations. — Ligation  of  the  S^ipcrficial Femoral  at  the  Apex 
of  Scarpa's  Triangle. — In  this  operation  the  position  is  supine 
with  the  thigh  and  leg  partly  flexed,  the  thigh  abducted, 
everted,  and  rested  upon  its  outer  surface  on  a  pillow.  The 
operator  stands  to  the  outside  of  the  leg.  From  a  point  cor- 
responding to  the  middle  of  the  triangle,  and  two  and  a  half 
inches  below  Poupart's  ligament,  make  a  three-inch  incision 


DISEASES  A. YD   INJURIES   OF  HEART  AND    VESSELS.     305 

in  the  arterial  line.  Cut  the  skin  and  superficial  fascia.  The 
saphenous  vein  will  not  be  seen  unless  the  incision  is  internal 
to  the  arterial  line ;  if  this  vein  is  seen,  draw  it  inward. 
Open  the  fascia  lata,  find  the  inner  border  of  the  sartorius 
muscle,  and  draw  it  outward.  The  fibers  of  this  muscle  run 
downward  and  inward,  thus  distinguishing  it  from  the  ad- 
ductor longus,  whose  fibers  run  downward  and  outward. 
Open  the  common  sheath  for  the  artery  and  vein,  and  then 
incise  the  individual  arterial  sheath.  Clear  the  artery  and 
pass  the  ligature  from  within  outward  (PI.  4.  Fig.  4). 

Ligation  of  the  Superficial  Femoral  in  Hunter  s  Canal. — In 
this  operation  the  position  is  the  same  as  in  the  above. 
Make  a  three-inch  incision  in  the  middle  third,  but  above 
the  middle  of  the  thigh,  parallel  with  the  arterial  line  and 
half  an  inch  internal  to  it  (Barker).  Incise  the  skin  and 
superficial  fascia,  look  out  for  the  internal  saphenous  vein, 
open  the  fascia  lata,  and  find  the  sartorius  and  retract  it 
inward,  thus  exposing  the  roof  of  Hunter's  canal,  which  is 
to  be  opened  for  an  inch  or  more.  Within  the  canal  is  seen 
the  long  saphenous  nerve,  usually  upon  the  sheath.  Open 
the  sheath  of  the  artery,  clear  the  vessel,  and  pass  the  needle 
from  without  inward. 

Iliac  Arteries. — The  line  of  the  common  and  external 
iliac  is  from  half  an  inch  below  and  half  an  inch  to  the  left 
of  the  umbilicus  to  midway  between  the  anterior  superior 
spine  of  the  ilium  and  the  pubic  symphysis.  The  upper 
third  of  this  line  represents  the  common  iliac,  and  the  lower 
two-thirds  the  external  iliac  (PI.  i.  Fig.  4). 

Anatomy. — The  common  iliac  arteries  arise  from  the  aorta 
opposite  the  left  side  and  lower  border  of  the  fourth  lumbar 
vertebra,  and  extend  to  the  upper  margin  of  the  right  and 
left  sacroiliac  joints,  where  they  each  bifurcate  into  an  exter- 
nal and  an  internal  iliac.  The  common  iliac  arteries  lie  upon 
the  fifth  lumbar  vertebra,  are  covered  with  peritoneum,  and 
are  crossed  by  the  ureters.  In  women  the  ovarian  arteries 
cross  the  common  iliacs.  The  common  iliac  veins  lie  to  the 
right  side  of  their  respective  arteries.  The  right  common 
iliac  artery  has  in  front  of  it,  besides  the  peritoneum  and 
ureter  (in  women  also  the  ovarian  artery),  the  ileum,  branches 
of  the  superior  mesenteric  artery,  and  branches  of  the  sym- 
pathetic nerve.  The  left  common  iliac  artery  has  in  front 
of  it,  in  addition  to  structures  common  to  both  sides  (ureter, 
ovarian  artery,  sympathetic  branches),  branches  of  the  infe- 
rior mesenteric  artery  and  the  sigmoid  flexure  with  its  meso- 
colon. The  internal  iliac  artery  runs  from  the  sacroiliac  joint 
20 


3o6  MODERN  SURGERY. 

to  the  upper  margin  of  the  great  sacrosciatic  foramen.  It  is 
very  rarely  Hgated  (only  in  gluteal  aneurysm,  uncontrollable 
hemorrhage  from  the  gluteal  or  sciatic  arteries,  or  to  pro- 
duce atrophy  of  the  prostate  gland).  The  external  iliac  runs 
from  the  sacroiliac  joint  along  the  pelvic  brim,  upon  the  inner 
edge  of  the  psoas  muscle,  to  Poupart's  ligament.  The  exter- 
nal iliac  vein  is  internal  to  the  artery.  On  the  right  side  high 
up,  it  passes  behind  the  artery.  The  external  iliac  artery  has 
in  front  of  it  peritoneum  and  subserous  tissue  (Abernethy's 
fascia).  The  ileum  crosses  the  right,  and  the  sigmoid  flexure 
the  left,  external  iliac.  The  genital  branch  of  the  genito- 
crural  nerve  crosses  the  artery  low  down,  and  the  circumflex 
iliac  vein  crosses  it  just  before  it  terminates  in  the  femoral. 
The  spermatic  vessels  and  the  vas  deferens  in  the  male,  the 
ovarian  vessels  in  the  female,  lie  upon  it,  low  down.  Some- 
times the  ureter  crosses  it  high  up.  We  find  the  spermatic 
vessels  in  the  male  and  the  ovarian  in  the  female  lying  for 
a  time  upon  the  inner  side  of  the  artery. 

Ligation  of  the  Iliac  by  Abdominal  Section. — The  best 
method  for  ligating  the  common,  the  external  or  the  in- 
ternal iliac  is  by  abdominal  section.  The  patient  is  placed 
in  the  Trendelenburg  position.  The  abdomen  is  opened 
in  the  midline  below  the  umbilicus.  The  intestines  are 
lifted  toward  the  diaphragm,  and  are  held  up  by  gauze 
pads.  The  edges  of  the  incision  are  retracted.  Select  the 
vessel  you  wish  to  tie  and  decide  where  you  wish  to  apply 
the  ligature.  Open  the  peritoneum  posteriorly  and  pass  the 
aneurysm  needle.  In  ligating  either  common  iliac,  pass  the 
needle  from  right  to  left.  In  ligating  the  external  iliac,  pass 
the  ligature  from  within  outward.  In  ligating  the  internal 
iliac  pass  the  needle  from  within  outward.  It  is  not  neces- 
sary to  suture  the  posterior  layer  of  peritoneum.  The  abdo- 
men is  closed  without  a  drain.  In  these  operations  be  sure 
and  push  the  ureter  out  of  the  way.  This  method  of  oper- 
ating is  endorsed  by  Dennis,  Hearn,  Marmaduke  Shield, 
Mitchell  Banks,  and  others. 

Ligation  of  the  External  Iliac  by  Abernethy' s  Extraperito- 
neal Method  (PI.  I,  Fig.  4).^The  position  of  the  patient  is 
recumbent  with  the  thighs  extended  during  the  first  incisions, 
but  in  the  latter  stages  of  the  operation  they  are  flexed  a  little 
to  relax  the  abdominal  structures.  The  operator  stands  to 
the  outside.  The  surgeon  will  find  the  artery  along  the  psoas 
muscle.  Mark  a  point  one  inch  above  and  one  inch  external 
to  the  middle  of  Poupart's  ligament,  and  another  point  one 
inch  above  and  one  inch  internal  to  the  anterior  superior  iliac 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     307 

spine  (Barker).  Join  these  two  points  by  a  curved  incision 
four  inches  long  and  convex  downward.  Cut  the  skin,  the 
fat,  the  two  obhque  and  the  transversaHs  muscles ;  open  the 
transversalis  fascia,  draw  the  peritoneum  inward  by  a  broad 


Fig.  64. — A,  Nephrotomy  :  a,  last  dorsal  n.  ;  b,  latissimus  dorsi  m.  ;  c,  serratus  post,  in- 
ferior m.  ;  d,  middle  layer  of  lumbar  fascia  ;  e,  outer  layer  ;  _/",  ext.  oblique  m.  ;  g,  int.  oblique 
m  ;  /;,  pennephritic  (extraperitoneal)  fat;  i,  quadratus  lumborum  m,  ;_/',  erector  spinse  m. 
B,  Nephrotomy  :  a.  first  lumbar  n.  ;  h,  kidney  :  c,  transversalis  fascia.  C,  Ligature  of  the 
sciatic  and  internal  pudic  arteries,  and  exposure  of  the  great  sciatic,  small  sciatic,  and  inter- 
nal pudic  nerves  :  a,  glutseus  maximus  m.  ;  b,  inf.  gluteal  n.  :  c,  sciatic  a.  ;  d,  int.  pudic  a. 
and  n. ;  e ,  great  sciatic  n.  ;  /,  small  sciatic  n  ;  g,  pyriformis  m.  D,  Ligature  of  the  gluteal 
artery  and  exposure  of  the  superior  gluteal  nerve  :  a,  glutseus  maximus  m.  ;  b,  gluteal  a.  ;  c, 
superior  gluteal  n. ;  d,  pyriformis  m.  ;  c,  glutaeus  medius  m.  (Kocher). 


retractor,  and  look  for  the  artery  along  the  pelvic  brim.  The 
anterior  crural  nerve  is  seen  external  to  the  artery,  the  vein 
is  internal  to  the  artery,  and  the  genitocrural  nerve  is  upon 
the  artery.     Clear  the  artery  near  its  middle  and  pass  the 


308  MODERN  SURGERY. 

ligature  from  within  outward.  In  Sir  Astley  Cooper's  ligation 
the  inguinal  canal  is  laid  open. 

The  Gluteal  Artery. — This  vessel  is  a  continuation  of 
the  posterior  division  of  the  internal  iliac.  It  emerges  from 
the  pelvis  at  the  upper  border  of  the  pyriformis  muscle.  It 
rests  upon  the  glutseus  minimus  and  divides  into  three 
branches,  and  is  covered  by  the  glutseus  maximus  muscle. 
The  superior  gluteal  nerve  lies  inferior  to  the  artery  (Fig.  64). 

Ligation. — Patient  is  prone.  The  surgeon  stands  to  the 
outside.  The  incision  corresponds  to  a  line  drawn  from  the 
posterior  superior  iliac  spine  to  the  upper  border  of  the  great 
trochanter.  Divide  the  skin,  fascia,  glutaeus  maximus  muscle, 
and  fascia  over  the  glutaeus  medius,  retract  the  glutseus  medius 
upward.  Feel  for  the  great  sacrosciatic  foramen,  and  at  this 
point  the  artery  is  found  above  the  pyriformis  muscle.  Clear 
the  vessel  and  pass  the  needle  from  below  upward  (see 
Kocher). 

The  Sciatic  Artery. — This  artery  is  the  larger  of  the 
terminal  branches  of  the  anterior  division  of  the  internal  iliac 
artery.  It  passes  to  the  lower  portion  of  the  great  sacrosci- 
atic foramen,  lying  back  of  the  internal  pudic  artery,  and  rest- 
ing upon  the  sacral  plexus  and  pyriformis  muscle  (Gray). 
It  leaves  the  pelvis  between  the  pyriformis  and  coccygeus 
muscles  and  passes  downward  between  the  ischial  tuberosity 
and  great  trochanter.  It  is  covered  by  the  glutaeus  maximus 
muscle,  rests  upon  the  gemelli,  internal  obturator  and  quad- 
ratus  femoris  muscles,  and  has  the  great  sciatic  nerve  exter- 
nal to  it,  and  the  small  sciatic  nerve  external  and  posterior 
(Fig.  64). 

Ligation. — Patient  lies  prone.  Surgeon  stands  to  outside. 
Incision  "  corresponds  to  the  middle  two-thirds  of  a  line  ex- 
tending from  the  posterior  inferior  iliac  spine  to  the  base  of 
the  great  trochanter."  ^  Cut  the  skin,  fat,  fascia,  and  glutaeus 
maximus  muscle.  Find  the  artery  at  the  lower  border  of  the 
pyriformis  muscle  and  trace  it  to  its  point  of  emergence  from 
the  pelvis.     Pass  the  ligature  from  without  inward. 

Internal  Pudic  Artery. — Is  one  of  the  terminal  branches 
of  the  anterior  trunk  of  the  internal  iliac.  It  runs  to  the 
lower  margin  of  the  great  sacrosciatic  foramen,  and  leaves 
the  pelvis  between  the  pyriformis  and  coccygeus  muscles, 
crosses  the  ischial  spine  and  again  enters  the  pelvis  by  the 
lesser  sacrosciatic  foramen.  The  vessel  is  accompanied  by 
the  internal  pudic  nerve  (Fig.  64). 

Ligation. — Position  and  incision  as  in  ligation  of  sciatic. 

1  Kocher's  Operative  Surgery,  by  Stiles. 


DISEASES  AND   INJURIES   OE  BONES  AND  JO/NTS.    3O9 

The  artery  is  found  below  the  ischial  spine.     Pass  the  needle 
from  below  upward  to  avoid  the  nerve. 


XIX.  DISEASES   AND    INJURIES   OF   BONES   AND 
JOINTS. 

I.  Diseases  of  the  Bones. 

Atrophy  of  bone  is  a  diminution  in  the  amount  of  bony- 
matter  without  change  in  osseous  structure.  It  arises  from 
want  of  use  (as  seen  in  the  wasting  of  the  bone  of  a  stump) 
or  from  pressure  (as  seen  in  the  destruction  of  the  sternum 
by  an  aneurysm  of  the  aorta).  Eccentric  atrophy  is  the 
thinning  of  a  long  bone  from  within,  the  outer  surface 
being  unchanged.  It  is  usually  a  senile  change.  Concentric 
atrophy  means  a  thinning  of  the  outer  surface  of  the  shaft, 
causing  a  lessened  diameter.  It  is  usually  linked  with  eccen- 
tric atrophy. 

Hypertrophy  of  bone  may  be  due  to  increased  blood- 
supply  (as  is  seen  in  chronic  epiphyseal  inflammation),  the 
bone  growing  much  more  than  does  its  fellow.  It  may  arise 
from  excessive  use  or  from  strain,  as  is  seen  in  the  increased 
size  of  the  fibula  when  the  tibia  is  congenitally  absent 
(Bowlby). 

Tumors  of  Bone. — Bones  give  origin  to  both  innocent 
and  malignant  tumors.  Myeloid  sarcoma  takes  origin  in 
the  endosteum  and  expands  the  bone.  The  fasciculated 
sarcoma  is  a  periosteal  growth.  Besides  these  growths  we 
find  osteomata,  chondromata,  and  secondary  deposits  of  can- 
cer and  sarcoma.  Primary  cancer  of  bone  does  not  exist. 
A  bone  may  become  cystic,  and  occasionally  the  cysts  are 
due  to  hydatids.  Gummata  are  the  commonest  growths 
found  springing  from  bone. 

Actinomycosis  of  Bone. — Most  usual  in  the  jaw,  but 
may  attack  the  orbit,  ribs,  sternum,  or  limbs  (p.    183). 

Tubercle  of  Bone. — Tends  especially  to  appear  in  the 
cancellous  ends  of  long  bones.  Is  apt  to  caseate  and  destroy 
large  amounts  of  bone.  The  bone  does  not  sclerose,  but 
undergoes  alterations  of  an  osteoporotic  nature  (see  p.  154). 

Osteitis,  Periostitis,  and  Osteoperiostitis. — Ostei- 
tis, or  inflammation  of  bone,  may  be  due  to  traumatism, 
to  a  constitutional  malady  or  diathesis,  to  the  extension  of 
inflammation  from  some  other  structure,  or  to  infection.  In 
inflammation  of  bone  the  exudation  flows  into  the  Haver- 
sian canals  and  spaces  and  the  canaliculi,  the  corpuscles  of 


310  MODERN  SURGERY. 

the  exudate  and  the  bone-corpuscles  proHferate,  embryonic 
tissue  forms,  the  bone  undergoing  thinning  (rarefaction),  not 
because  of  pressure,  but  because  of  absorption  by  voracious 
leukocytes  and  osteoclasts.  This  process  of  rarefaction  en- 
larges all  the  bony  spaces,  and  by  destroying  septa  throws 
many  of  the  spaces  into  one.  If  the  surface  of  a  bone  in- 
flames, the  periosteum  will  more  or  less  be  separated  by  the 
exudation  and  the  bone  will  be  covered  with  little  pits  or 
erosions.  Inflamed  bone  is  so  soft  that  it  can  readily  be  cut 
with  a  knife. 

Osteitis  may  terminate  in  resoliitio7i  or  it  may  terminate  in 
sclerosis,  the  exudate  being  converted  first  into  fibrous  tissue 
and  next  into  dense  bone  with  only  a  few  small  cancellous 
spaces.  If  the  exudation  is  under  the  periosteum,  the  bone 
will  be  thickened  at  this  point,  bone  stalactites  marking  the 
points  of  passage  of  the  vessels.  Osteitis  may  terminate  in 
suppuration,  this  condition  being  known  as  "  caries!'  In 
tubercular  osteitis  caseation  of  the  inflammatory  products 
is  very  apt  to  arise  (tubercular  or  strumous  caries).  Acute 
osteitis  may  terminate  in  necrosis.  Osteitis  is  usually  asso- 
ciated with  more  or  less  periostitis.  A  simple  acute  peri- 
ostitis without  involvement  of  the  bone  can  arise  from  trau- 
matism, but  in  all  severe  cases  of  periostitis,  in  all  chronic 
cases,  in  all  cases  due  to  syphilis,  rheumatism,  measles,  scar- 
latina, or  enteric  fever  the  bone  is  involved  at  the  same 
time  or  subsequently.  In  syphilitic  states  gummatous  de- 
generation frequently  ensues. 

Symptoms  of  Osteitis  and  Osteoperiostitis. — As  a 
chronic  process  the  symptoms  of  osteitis  are  commonest  in  the 
femur.  Its  history  usually  exhibits  a  record  of  a  cold  or  an 
injury.  Pain  is  severe,  boring  or  aching  in  character,  deep- 
seated,  worse  at  night,  and  aggravated  by  a  dependent  position 
of  the  part.  The  symptoms  closely  resemble  those  of  perios- 
titis, with  which  disease  it  is  almost  sure  to  be  hnked.  Ten- 
derness exists  on  percussion,  and  sometimes  on  pressure. 
Subperiosteal  swelling,  fusiform  in  shape,  is  noted ;  cutaneous 
edema  and  discoloration  are  observed  if  a  superficial  bone 
be  involved.  In  syphilis,  atrophic  osteitis  may  attack  the 
cranial  bones  and  produce  softening  or  even  perforation,  or 
osteophytic  osteitis  may  arise,  exostoses  being  formed. 
Osteoperiostitis  may  be  acute  or  chronic,  circumscribed  or 
diffused,  and  may  terminate  in  resolution,  organization,  or 
suppuration.  It  arises  from  cold,  blows,  wounds,  strains, 
the  spread  of  adjacent  inflammation,  specific  febrile  maladies, 
pyogenic  infection,  syphilis,  rheumatism,  or  tubercle.     The 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.    3  I  I 

symptoms  are  pain  (which  is  worse  at  night  and  which  is 
aggravated  by  motion,  pressure,  or  a  dependent  position), 
swelHng,  edema,  and  discoloration  of  the  soft  parts.  Pain 
in  the  syphiUtic  form  is  not  so  severe  as  in  other  varieties. 
Acute  ?iccrosis  or  diffuse  periostitis,  a  septic  inflammation 
of  bone  and  periosteum,  is  commonest  in  boys  about  the 
age  of  puberty.  It  is  usually  due  to  cold,  a  specific  fever, 
or  injury,  and  generally  affects  the  tibia  or  femur ;  the  symp- 
toms locally  are  severe ;  redness,  swelUng,  and  pain  are 
marked  ;  constitutionally  there  are  rigors,  fever,  or  convul- 
sions. Necrosis  is  apt  to  result.  Pyemia  is  common.  Some 
fever  always  exists.  In  simple  acute  periostitis  a  swelling  is 
felt  upon  the  osseous  surface.  The  swelling  is  firmly  fixed 
and  is  very  tender,  but  the  bone  itself  is  not  enlarged.  There 
is  some  local  heat,  discoloration,  often  fever,  and  the  patient 
complains  of  an  aching  pain,  which  is  worse  at  night. 

Treatment  of  Osteitis  and  Osteoperiostitis. — In  syphilitic 
forms  the  treatment  consists  of  rest,  elevation  of  the  part, 
the  local  use  of  iodin  and  mercurial  ointment,  and  bandag- 
ing. Specific  treatment  is  by  the  stomach  or  hypodermati- 
cally.  Operation  is  rarely  justifiable.  In  other  forms,  if 
the  case  be  recent  and  severe,  put  the  patient  to  bed,  place 
the  limb  in  a  splint  and  elevate  it,  apply  leeches,  cold,  and 
lead-water  and  laudanum,  use  a  bandage,  and  order  salines 
and  iodid  of  potassium.  Morphin  is  used  for  pain.  If  these 
means  fail,  order  counterirritation  by  iodin  and  blue  oint- 
ment or  blisters,  and  use  heat  locally.  In  severe  cases  take 
a  tenotome  and  slit  the  periosteum  subcutaneously  to 
reliev^e  tension  ;  this  procedure  often  instantly  relieves  the 
pain.  Some  cases  demand  a  longitudinal  osteotofny,  which 
is  performed  by  taking  Hey's  saw  and  dividing  the  bone 
longitudinally  into  the  medullary  canal.  If  pus  forms,  drain 
at  once. 

Diffuse  osteoperiostitis  requires  early  and  free  incisions, 
antiseptics,  drainage,  rest  and  deviation  of  the  limb,  and 
strong  supporting  and  stimulating  treatment.  Amputation 
is  sometimes  demanded,  as  when  the  patient  grows  weaker 
and  weaker  even  after  incision,  and  when  a  joint  is  seriously 
involved.  If  the  necrosis  affects  the  entire  shaft,  which 
separates  from  its  epiphyses,  and  new  bone  has  not  yet 
formed  from  the  periosteum,  make  a  subperiosteal  resection 
of  the  shaft. 

Chronic  periostitis  is  usually  syphilitic.  A  node  is  a 
chronic  inflammation  of  the  deep  periosteal  layers.  Nodes 
occurring  early  in  the  secondary  stage  remain  soft  and  soon 


312  MODERN  SURGERY. 

pass  away,  but  those  occurring  two  years  or  more  after 
infection  are  apt  to  cause  a  bony  deposit.  A  node  may 
suppurate,  leaving  a  sinus  at  the  bottom  of  which  is  a  piece 
of  dead  bone.  Gumma  of  the  periosteum  is  one  form  of 
node  which  is  apt  to  produce  caries  or  necrosis. 

Osteoplastic  periostitis  accompanies  chronic  osteitis  and 
causes  the  deposit  of  new  bone  which  undergoes  sclerosis. 
The  chief  symptom  is  aching  pain,  which  is  worse  when 
warm  in  bed,  and  is  aggravated  by  damp  and  wet.  A 
swelling  is  found  at  the  seat  of  pain  (often  over  the  tibia, 
ulna,  clavicle,  or  sternum).  The  soft  parts  are  uninflamed 
and  move  freely  unless  softening  or  suppuration  has  occurred. 
Tenderness  is  manifest. 

Treatment. — For  the  nodes  of  early  syphilis  use  mercurial 
treatment ;  for  the  nodes  of  late  syphilis  give  mercury  and 
large  advancing  doses  of  iodid  of  potassium.  Blisters,  blue 
ointment,  and  iodin  used  locally,  and  subcutaneous  division 
of  periosteum,  are  of  value.  If  suppuration  occurs,  open 
antiseptically. 

Abscess  of  bone  is  due  to  tubercular  infection.  It 
is  always  chronic,  never  acute.  A  very  acute  inflamma- 
tion, such  as  is  induced  by  pyogenic  organisms,  causes 
acute  necrosis  rather  than  an  acute  abscess.  After  a  chronic 
abscess  begins  mixed  infection  may  take  place,  the  seat 
of  abscess  being  a  point  of  least  resistance.  Chronic  ab- 
scess of  bone  was  first  described  by  Sir  Benjamin  Brodie, 
and  is  often  called  "  Brodie's  abscess."  It  occurs  in  the 
cancellous  structure  of  the  ends  of  bones — usually  in  the 
head  of  the  tibia,  sometimes  in  the  femur  or  humerus.  The 
cause  of  bone-abscess  is  injury  which  induces  osteitis ;  bone- 
rarefaction  forms  a  cavity,  the  inflammatory  products  case- 
ate  and  sometimes  suppurate,  and  the  surrounding  bone 
thickens  and  hardens  because  of  growth  from  the  perios- 
teum. The  abscess  is  apt  to  break  into  a  joint,  as  the  joint- 
surface  is  not  covered  by  periosteum  and  no  barrier  of  bone 
is  there  formed.     Brodie's  abscess  may  induce  necrosis. 

Symptoms. — The  symptoms  are  like  those  of  osteo- 
periostitis, only  they  are  localized  and  persistent.  These 
symptoms  are  thickening  of  bone  and  soft  parts,  edema 
and  discoloration  of  skin,  tenderness,  constant  pain  (sub- 
ject to  violent  exacerbations  and  made  worse  by  motion, 
pressure,  or  a  dependent  position),  and  attack  after  attack 
of  synovitis  in  the  nearest  joint.  Fever  and  sweats  may  be 
noted. 

Treatment. — In  treating  bone-abscess,  trephine  the  bone 


D/SEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    313 

at  the  point  of  the  greatest  tenderness,  and  if  the  abscess  is 
missed,  follow  the  advice  of  Holmes  and  perforate  the  wall 
of  bone  with  the  trephine,  opening  in  several  directions  to 
discover  the  pus.  It  is  often  easy  to  open  into  the  abscess 
with  a  chisel  or  gouge.  If  the  abscess  opens  into  a  joint, 
trephine  the  bone  and  open  and  drain  the  joint.  After 
opening  the  cavity  gouge  its  walls  clean,  dry  with  gauze, 
touch  with  pure  carbolic  acid,  and  pack  with  iodoform  gauze. 

Caries  is  suppurative  osteitis,  a  molecular  osseous  de- 
struction. In  some  cases  caries  is  a  name  given  to  sup- 
purative osteitis,  in  others  to  tubercular  osteitis,  in  still 
others  to  gummatous  osteitis.  Osteitis  is  apt  to  become 
purulent  when  the  bone  is  exposed  to  the  air,  when  rest  is 
not  secured,  when  the  health  of  the  individual  is  below  nor- 
mal, when  a  foreign  body  such  as  a  bullet  is  in  the  bone,  or 
when  tubercle  or  syphilis  exists.  When  caries  arises,  the 
softened  and  granulating  bone  breaks  down  and  is  dis- 
charged through  a  sinus.  After  drainage  is  secured  or- 
ganization, sclerosis,  and  healing  result.  In  these  cases 
new  bone  usually  forms,  and  a  cure  results. 

Tubercular  caries,  due  to  caseation  of  the  products  of  an 
osteitis  in  a  tubercular  subject,  shows  no  tendency  to  self- 
cure,  no  organization  or  sclerosis  takes  place  and  no  new 
bone  forms.  The  interior  of  bones,  especially  of  the  carpus 
and  tarsus,  being  entirely  softened  and  destroyed,  thin  shells 
only  are  left. 

Caries  necrotica  is  a  condition  in  which  small  but  visible 
portions  of  soft  and  dead  bone  are  cast  off;  caries  sicca  is 
molecular  death  of  bone  without  suppuration. 

The  caseating  masses  in  tubercular  caries  contain  the 
tubercle  bacillus.  If  a  tubercular  collection  is  evacuated 
and  infection  with  pus  organisms  occurs,  genuine  suppuration 
takes  place,  and  constitutional  infection  causes  suppurative 
fever,  and  may  cause  death.  Purulent  osteitis  may  affect 
any  part  of  any  bone,  but  caseous  osteitis  (tubercular 
caries)  tends  to  arise  especially  in  cancellous  structures 
(heads  of  long  bones,  vertebral  bodies,  ribs  and  sternum, 
and  bones  of  the  carpus  and  tarsus).  Tubercular  osteitis 
of  the  shaft  of  a  long  bone  occasionally,  but  rarely,  arises. 
Tubercular  osteitis  is  apt  to  cause  tubercular  disease  in  an 
adjacent  joint.  Cold  abscesses  are  frequently  due  to  tuber- 
cular osteitis. 

Symptoms. — In  the  beginning  the  evidences  of  caries 
are  usually  those  of  osteitis,  but  the  first  sign  noted  may 
be  a  fluctuating  swelling  due  to  pus  or  to  caseated  tubercles. 


314  MODERN  SURGERY. 

After  a  time,  at  any  rate,  a  fluctuating  swelling  is  discovered. 
If  not  opened,  the  abscess  breaks,  voids  its  contents,  and 
leaves  a  sinus  from  which  runs  a  purulent  matter  which 
after  a  time  becomes  thin,  reddish,  and  irritating  to  the  skin, 
contains  small  portions  of  gritty  bone,  and  has  a  foul  smell. 
The  opening  of  the  sinus  fills  up  with  edematous  granu- 
lations. A  probe  introduced  to  the  bottom  of  the  sinus 
finds  bone  which  is  sieve-like  (worm-eaten),  and  which  on 
being  struck  gives  a  muffled  note  rather  than  the  clear, 
sharp  note  of  necrosis ;  the  bone  is  rough,  is  bared,  and  is  so 
soft  that  the  probe  can  usually  be  stuck  into  it.  In  old  cases 
of  caries  amyloid  disease  may  arise. 

Treatment. — If  syphilis  exists,  give  iodid  of  potassium  in 
advancing  doses  and  a  mild  mercurial  course.  If  tubercle  ex- 
ists, give  iodid  of  iron,  arsenic,  cod-liver  oil,  and  nourishing 
foods,  and  recommend  a  change  of  air.  Locally,  in  all  cases, 
insist  on  rest  and  at  once  secure  drainage,  enlarging  the  open- 
ing if  necessary  and  inserting  a  tube,  and  even  making  addi- 
tional openings  ;  syringe  often  with  antiseptic  fluids  and  dress 
antiseptically.  If  the  case  is  seen  before  the  abscess  has 
opened,  open  it  under  strict  antiseptic  precautions.  When  the 
case  is  found  to  be  chronic  there  arises  the  question  of  opera- 
tion. Incomplete  operations  are  worse  than  useless,  for  they 
may  cause  pyemia,  and  if  the  case  be  tubercular  may  inaugu- 
rate systemic  diffusion  of  the  infection.  If  the  gouge  is  used, 
try  to  remove  all  carious  bone.  The  diseased  bone  is  white, 
crumbles  up,  and  does  not  bleed ;  the  non-carious  bone  is 
pink  and  vascular.  Scrape  away  all  granulations  ;  swab  out 
the  cavity  with  pure  carbolic  acid  and  pack  it  with  iodoform 
gauze.  Instead  of  gouging  away  bone,  there  may  be  used 
the  actual  cautery,  sulphuric  acid,  or  hydrochloric  acid.  In 
severe  cases  excision  is  required,  and  in  some  very  rare  cases 
amputation  may  be  necessary.  Caries  of  the  spine  is  con- 
sidered under  Diseases  of  the  Spine. 

Necrosis  is  the  death  of  visible  portions  of  bone  from 
circulatory  impediment.  It  is  analogous  to  gangrene.  The 
cause  of  necrosis  is  injury  (such  as  the  tearing  off  of  perios- 
teum) which  deprives  the  bone  of  blood.  Inflammation  of 
the  periosteum  further  lessens  the  nutrition.  Acute  inflam- 
mation in  bone  causes  necrosis,  the  excessive  exudation  in 
the  canals  and  spaces  obliterating  the  blood-vessels  by 
pressure.  The  occlusion  of  vessels  by  septic  thrombi  may 
lead  to  necrosis,  or  the  direct  action  of  toxins  may  first 
inflame  and  finally  destroy  a  portion  of  the  bone.  A  thin 
shell    of  bone    only  may  necrose   from    periosteal    separa- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    315 

tion,  or  an  entire  shaft  may  die  from  acute  osteomyelitis 
or  diffuse  infective  periostitis.  Osteomyelitis  is  the  most 
usual  cause  of  necrosis.  Necrosis  is  most  frequently  met 
with  in  the  diaphyses  of  the  long  bones,  caries  in  the  heads 
of  the  bones.  A  sequestrum  may  form  in  a  vertebral  body, 
in  the  carpus,  or  in  the  tarsus,  but  rarely  does  ;  hence,  we 
conclude  that  sequestra  do  not  often  result  from  tubercular 
osteitis.  A  fragment  of  dead  bone  is  a  foreign  body ;  the 
healthy  bone  adjacent  to  it  inflames,  softens,  and  granulates, 
and  this  line  of  granulation,  like  the  line  of  demarcation  of 
gangrene,  separates  the  dead  part  from  the  living,  the  white 
dead  bone  being  surrounded  by  the  red  zone  of  granulation- 
tissue.  A  bit  of  dead  bone  is  called  a  "  sequestrum,"  and 
Nature  tries  to  cast  it  off.  A  superficial  sequestrum  is  known 
as  an  "  exfoliation." 

Nature's  method  of  casting  off  a  sequestrum  is  as  follows : 
suppuration  takes  place  at  the  line  of  demarcation,  osteitis 
extends  for  a  considerable  distance  around  this  line,  the  peri- 
osteum shares  in  the  inflammation,  and  new  bone  forms.  A 
cavity  thus  forms  within  by  suppuration,  and  a  box  or  case 
forms  without  by  ossification,  the  now  entirely  loosened  se- 
questrum being  so  encased  that  it  cannot  escape.  The  pus 
finds  its  way  through  the  new  bone,  and  there  is  presented 
the  condition  so  often  seen  by  the  surgeon — namely,  a  case 
of  new  bone  known  as  the  "  involucrum,"  a  cavity  containing 
pus  and  the  dead  fragment  or  sequestrum,  and  a  discharging 


Fig.  65. — Diagram  illustrating  the  formation  of  a  sequestrum  :  ^,  sound  bone;   5,  new 
bone  ;   C,  granulations  lining  involucrum  ;  D,  cloaca  ;  E,  sequestrum. 


sinus  or  "  cloaca "  (Fig.  65).     Nature   may   eventually  get 
rid  of  the  fragment,  but  the  surgeon  should  not  wait. 

When  a  portion  of  the  bone  surrounding  the  medullary 
canal  dies  the  condition  is  called  "  central  necro.sis."  In 
some  rare  cases  necrosis  occurs  without  apparent  suppura- 


3l6  MODERN  SURGERY. 

tion,  a  painless  swelling  of  bone  simulating  sarcoma.  Mer- 
cury is  a  cause  of  necrosis.  The  fumes  of  phosphorus  may 
cause  necrosis  of  the  lower  jaw  in  those  with  decayed  teeth. 
Osteomyelitis  is  the  usual  cause  of  necrosis.  It  may  be  pro- 
duced also  by  frost-bites  and  burns.  Many  fevers  (measles, 
typhoid,  scarlet  fever^  etc.)  are  occasionally  followed  by  ne- 
crosis.    SyphiHs  and  tubercle  are  occasional  causes. 

Symptoms. — The  symptoms  of  necrosis  are  at  first  those 
of  osteitis  or  osteomyelitis.  The  abscess,  when  formed,  opens 
of  itself  or  is  opened  by  the  surgeon,  and  a  sinus  or  sinuses 
form  in  the  soft  parts  as  happens  in  caries.  A  probe  intro- 
duced into  the  sinus  strikes  upon  hard  bone  with  a  clear, 
ringing  note,  and  often  finds  a  sinus  or  sinuses  in  the  bone. 
In  superficial  necrosis  the  discharge  is  slight  and  the  probe 
shows  the  limitations  of  the  disease.  In  extensive  necrosis 
the  discharge  is  profuse,  much  new  bone  forms,  several  sinuses 
form  far  apart,  and  the  probe  must  pass  a  considerable  thick- 
ness of  new  bone  before  it  finds  the  bit  of  dead  bone.  The 
surgeon  should  not  operate  until  the  dead  bone  is  separated 
from  the  living,  until  a  line  of  demarcation  forms,  and  until 
the  sequestrum  is  loose.  In  youth  dead  bone  loosens  quickly, 
but  in  old  age  slowly.  An  exfoHation  becomes  loose  sooner 
than  the  sequestrum  of  central  necrosis.  In  diffuse  periostitis 
the  necrosed  shaft  loosens  quickly.  Necrosed  portions  of 
the  upper  extremity  loosen  more  rapidly  than  those  of  the 
lower.  Chilton  states  that  in  the  young  adult  two  or  three 
months  will  be  required  to  loosen  a  necrosed  fragment  in  the 
lower  extremity,  and  from  six  weeks  to  two  months  in  the 
upper  extremity.  A  loose  sequestrum  may  be  moved  by  the 
probe,  and  when  struck  gives  a  hollow  note.  In  old  cases 
there  is  always  danger  that  amyloid  disease  may  arise. 

Treatment, — An  exfoliation  is  removed  as  soon  as  it  is 
loose,  the  seat  of  trouble  is  touched  with  pure  carbolic  acid 
and  packing  of  iodoform  gauze  is  inserted.  The  treatment 
of  central  necrosis  comprises  free  incisions  for  drainage, 
antiseptic  dressing,  frequent  cleansing,  rest,  good  food, 
stimulants,  and  tonics.  When  the  sequestrum  becomes 
loose,  break  through  the  involucrum  with  the  chisel,  gouge, 
and  rongeur,  remove  the  dead  bone  with  the  forceps,  clean 
the  cavity  with  pure  carbolic  acid  and  pack  with  iodoform 
gauze.  This  operation  is  known  as  "  sequestrotomy."  If 
much  of  a  gap  is  left  by  the  operation,  try  to  fill  this  gap 
by  taking  flaps  of  skin  and  fastening  them  to  the  bottom,  by 
breaking  the  edges  of  the  involucrum  and  turning  them  in, 
or  by  inserting  bone-chips.    These  chips,  which  are  obtained 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    317 

from  the  compact  part  of  the  tibia  or  femur  of  an  ox,  are 
decalcified  by  being  placed  for  a  couple  of  weeks  in  a  10  per 
cent,  aqueous  solution  of  hydrochloric  acid  (which  is  renewed 
every  day) ;  they  are  well  washed  in  a  weak  alkali  and  then 
in  water,  are  cut  into  strips,  are  soaked  for  two  days  in  a 
I  :  1000  sublimate  solution,  and  are  kept  in  a  saturated  ethe- 
real solution  of  iodoform.  The  cavity  is  made  sterile  and  is 
well  dusted  with  iodoform,  the  bone-chips  are  dried  and  in- 
serted into  the  cavity,  a  capillar)^  drain  is  employed,  the  peri- 
osteum is  stitched  over  the  opening,  and  so  are  the  soft  parts; 
but  if  this  cannot  be  done,  iodoform  packing  is  used  to  keep 
the  chips  in  place.  This  method  we  owe  to  the  genius  of  Senn. 
Attempts  have  been  made  to  fill  bone-cavities  with  gutta- 
percha, plaster-of-Paris,  etc.  (Martin).  The  difficulty  is  to 
completely  asepticize  the  walls  of  the  cavity.  Dressman  has 
advised  for  this  purpose  the  use  of  boiling  oil,  but  it  is  apt 
to  cause  superficial  necrosis.  Schleich  uses  formalin-gelatin 
to  fill  bone-cavities.  In  some  cases  of  extensive  necrosis  due 
to  diffuse  infective  osteoperiostitis  or  to  osteomyelitis  exten- 
sive resection  or  even  amputation  may  be  necessary. 

Acute  difiuse  osteomyelitis,  a  diffuse  inflammation  of 
bone  and  marrow,  is  due  to  infection  with  pyogenic  organisms 
(staphylococcus  pyogenes  aureus  and  streptococcus  pyo- 
genes), or  to  mixed  infection  of  the  pyogenic  organisms  with 
the  organisms  of  typhoid  fever,  of  tubercle,  etc.  It  may 
arise  from  a  wound,  such  as  a  compound  fracture,  a  gunshot- 
injury,  or  an  amputation.  It  may  occur  when  the  infection 
has  been  by  way  of  the  blood.  The  causative  organisms 
may  enter  the  circulation  through  the  lymphatic  system  or 
may  pass  directly  into  the  blood  from  a  focus  of  suppuration 
in  the  skin,  in  the  subcutaneous  structures,  or  some  deeper 
part.  The  organisms  may  have  been  taken  into  the  system 
by  the  tonsil  or  respiratory  organs  (Kraske),  the  intestinal 
canal  (Kocher),  the  genito-urinary  tract,  or  from  excoriations, 
bruises,  or  small  wounds  in  the  skin  (Warren).  The  exan- 
themata strongly  predispose  to  osteomyelitis.  Typhoid  fever, 
typhus  fever,  small-pox,  and  malarial  fever,  lessen  the  vital 
resistance  of  marrow.  Some  observers  teach  that  the  ty- 
phoid bacillus  is  pyogenic  (Frankel),  but  others  think  that 
the  toxins  of  the  typhoid  organism  weaken  the  marrow  and 
suppuration  arises  because  of  mixed  infection  with  pyogenic 
bacteria  (Park  and  Klemm).  Keen  insists  that  the  typhoid 
bacillus  has  occasionally  pyogenic  power.^  In  osteomyelitis 
from  wound  of  the  endosteum  the  medulla  and  cancellous 

1  Surgical  Complications  and  Sequels  of  Typhoid  Fever,  by  \V.  W.  Keen. 


3l8  MODERN  SURGERY. 

tissue  inflame  and  suppurate.  The  entire  length  and  thickness 
of  the  shaft  may  be  involved,  and  the  periosteum  becomes 
infiltrated,  detached,  and  retracted  from  the  edges  of  the 
bone-wound.  The  soft  tissues  around  the  bone  also  inflame 
and  sometimes  slough.     More  or  less  necrosis  is  inevitable. 

The  symptoms  of  acute  diffuse  osteomyelitis  from  wound 
are — a  very  severe  boring,  gnawing,  aching  pain  ;  great  ten- 
derness ;  deep  swelling  of  the  soft  parts  over  the  bone ;  the 
skin  is  healthy  early  in  the  case  ;  a  profuse  offensive  purulent 
discharge  containing  bone-fragments  and  tissue-sloughs  is 
poured  out ;  the  periosteum  is  red,  thick,  and  separated ;  a 
fungating  foul  mass  protrudes  from  the  medullary  canal ; 
rigors,  sweats,  and  fever  point  to  septicemia  or  pyemia. 

Treatment. — In  treating  acute  diffuse  osteomyelitis  expose 
the  interior  of  the  bone,  curet  the  medullary  cavity,  swab  it  out 
with  pure  carbolic  acid,  and  pack  it  with  iodoform  gauze ; 
drain  ;  apply  antiseptic  dressings  ;  frequently  cleanse  ;  and  use 
strong  supporting  treatment.  When  the  sequestrum  loosens, 
it  should  be  removed.     Some  cases  require  amputation. 

Acute  Bpipliysitis. — Acute  osteomyelitis  without  a 
wound  is  called  "  acute  infantile  arthritis  "  or  "  acute  epiph- 
ysitis." It  affects  the  young,  especially  children  of  from 
one  to  two  years  of  age,  but  occasionally  arises  in  older 
persons  (ten  to  fourteen  years).  It  begins  at  the  epiphyseal 
line.  A  strain  may  occur  at  this  point,  inflammation  follows, 
and  a  hospitable  welcome  is  extended  to  micro-organisms 
which  are  contained  in  the  body-fluids  and  which  pass 
through  this  area.  In  some  cases  chilling  of  the  body  is 
the  predisposing  cause.  In  some  patients  no  history  of 
injury  is  obtainable ;  a  preceding  illness,  especially  a  specific 
fever,  being  responsible  for  the  weakening  of  tissue-resistance. 
New  tissues  are  always  more  susceptible  to  infection  than 
old  tissues,  and  one  of  the  most  susceptible  of  new  tissues  is 
the  young  bone  at  the  end  of  the  diaphysis.  Septic  organ- 
isms may  lodge  in  this  area,  multiply  there  and  produce 
systemic  poisons.  The  femur  and  tibia  are  the  bones  most 
often  attacked,  the  hip-joint  or  knee-joint  being  secondarily 
involved ;  the  humerus,  tibia,  radius,  ulna,  and  other  bones 
may  be  attacked ;  the  shoulder-,  ankle-,  or  elbow-joint  may 
become  secondarily  affected.  The  youngest  bone  around 
the  ossific  centre  first  inflames,  necrosis  takes  place,  a  small 
sequestrum  forms,  and  the  pus  around  the  sequestrum  is  apt 
to  make  a  cloaca  and  empty  into  the  adjacent  joint,  lighting 
up  a  suppurative  inflammation  of  the  articulation,  and  into 
the  medullary  canal,  causing  diffuse  osteomyelitis. 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.    319 

The  symptoms  of  acute  epiphysitis  usually  come  on  sud- 
denly and  especially  at  night,  and  the  attack  may  be  so  acute 
as  to  cause  death  by  systemic  poisoning  before  a  diagnosis 
is  arrived  at.  The  disease  is  generally  ushered  in  by  a  chill, 
which  is  followed  by  septic  febrile  temperature.  The  history 
will  sometimes  contain  the  statement  that  the  patient  was 
suddenly  chilled  after  being  overheated  (sitting  in  a  draft  or 
in  a  cellar  on  a  hot  day,  possibly  swimming  when  very 
warm,  etc.).  There  is  violent,  burning,  aching  pain  in  the 
bone  and  great  tenderness  near  the  joint ;  the  soft  parts, 
which  at  first  are  healthy  in  appearance,  after  a  time  dis- 
color, swell,  and  present  distended  veins ;  the  neighboring 
joint  swells,  and  may  become  filled  with  pus ;  the  peri- 
osteum and  the  shaft  are  involv^ed  for  a  considerable  dis- 
tance ;  each  epiphysis  may  become  affected,  the  shaft  be- 
tween being  comparatively  uninvolved,  and  the  epiphyses 
may  separate,  displacement  and  shortening  taking  place.  This 
disease  is  often  mistaken  for  rheumatism  because  of  the  joint- 
swelling,  occasionally  for  typhoid  fev'er  because  of  the  fever, 
and  in  some  cases  for  erysipelas  because  of  the  redness  of 
the  skin.  It  gives  a  voxy  grave  prognosis.  Sometimes  an 
epiphysitis  shows  milder  symptoms  and  is  slower  in  progress 
(subacute).  These  cases  are  \'ery  often  mistaken  for  rheu- 
matism. But  in  rheumatism  the  joint  is  the  part  involved 
from  the  beginning,  while  in  epiphysitis  the  joint  is  involved 
secondarily  after  obvious  evidence  of  inflammation  well  clear 
of  the  articulation.  Further,  the  symptoms  of  rheumatism 
can  be  rapidly  improved  by  the  use  of  the  alkalies  or  the 
salicylates. 

Treatment. — In  treating  acute  epiphysitis  do  not  wait  for 
fluctuation,  but  incise  at  once ;  break  through  the  bone  at 
one  or  more  points  with  a  gouge  or  chisel ;  curet ;  chisel 
away  the  diseased  bone,  and  if  necessar>^  curet  the  medul- 
laiy  canal ;  irrigate  with  corrosive-sublimate  solution  ;  swab 
out  with  pure  carbolic  acid  ;  use  iodoform  plentifully  ;  pack  ; 
drain  the  joint  if  it  is  involved ;  employ  rest,  anod}aies,  and 
strong  supporting  treatment.  Remove  dead  bone  subse- 
quently when  it  becomes  loose.  Amputation  may  be 
required. 

Chronic  osteomyelitis  is  usually  linked  with  osteitis. 
It  ma\'  e\-entuate  in  osteosclerosis  with  filling  up  of  the 
medullary  canal,  or  in  limited  suppuration,  or  in  caseation 
of  the  cancellous  tissue  (Brodie's  abscess),  or  in  necrosis. 
A  tubercular  inflammation  is  one  form  of  chronic  osteo- 
myelitis.    Syphilis,  typhoid  fever,  etc.,  may  cause  it. 


320  MODERN  SURGERY. 

Osteomalacia,  or  Mollities  Ossium. — In  this  disease 
the  bones  are  partly  decalcified,  and  consequently  soften  and 
bend.  Many  bones  are  usually  involved.  It  is  commoner 
beyond  than  before  middle  age,  though  it  may  occur  in 
infancy ;  it  is  commoner  in  women  than  in  men,  and  preg- 
nancy seems  to  bear  more  than  a  casual  relation  to  its  pro- 
duction. In  osteomalacia  the  medulla  increases  in  bulk 
and  becomes  more  fatty,  and  the  osseous  matter  is  absorbed 
gradually,  first  from  cancellous  tissue  and  then  from  the 
compact  tissue.  Some  observers  believe  this  curious  con- 
dition is  due  to  lactic  acid  in  the  blood. 

Symptoms. — The  symptoms  of  osteomalacia  are  as  fol- 
lows :  many  points  of  pain  which  are  often  thought  to  be 
due  to  rheumatism ;  deformities  from  twisting  and  bending 
of  bone ;  and  a  large  excess  of  calcium  salts  in  the  urine. 
This  disease  lasts  a  number  of  years,  but  usually  causes 
death  from  exhaustion,  though  some  few  cases  are  arrested 
or  cured.     Fractures  occur  from  very  slight  force. 

Treatment. — In  treating  osteomalacia  in  women  insist 
that  pregnancy  must  not  occur.  Put  braces  and  supports 
upon  distorted  limbs  to  prevent  fracture.  Advise  good  air, 
hygienic  surroundings,  and  nourishing  food.  Among  the 
medicines  that  can  be  used  may  be  mentioned  cod-liver  oil, 
lime  salts,  preparations  of  phosphorus,  and  bone-marrow. 
In  women  the  removal  of  the  ovaries  sometimes  cures.  It 
has  been  asserted  that  the  production  of  anesthesia  by 
means  of  chloroform  is  of  great  benefit. 

Acromegfaly. — This  is  a  disease  which  causes  progres- 
sive and  often  great  enlargement  of  both  the  bones  and  soft 
parts  of  the  extremities,  which  enlargement  is  symmetrical. 
The  lower  jaw  projects  in  advance  of  the  upper  jaw,  the 
nose  becomes  prominent  and  thick,  the  supra-orbital  ridges 
are  accentuated,  and  the  costal  cartilages  and  inner  ends  of 
the  clavicles  become  protuberant.  Later  the  lar}.'nx,  ribs, 
shoulder-blades,  and  vertebra  become  involved,  and  the 
back  becomes  markedly  humped  (cervicodorsal  hump).  The 
hands  and  feet  are  affected  in  advanced  cases.  As  a  rule, 
the  thyroid  gland  is  enlarged,  and  a  postmortem  examina- 
tion may  detect  an  enlarged  pituitary  gland.  Severe  and 
uncontrollable  headache  is  sometimes  a  distressing  feature 
of  the  disease.  Treatment  is  futile.  The  disease  slowly  but 
surely  causes  death. 

I^eontiasis  Ossium  (Virchow's  Disease). — This  is  a 
hypertrophy  limited  to  the  facial  and  cranial  bones,  which  is 
symmetrical,  and   which   begins,  as   a   rule,  in   the   superior 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.     32 1 

maxillse.  The  hypertrophy  progressively  increases,  causes 
difficulty  of  mastication,  and  is  accompanied  by  headache. 
It  produces  distinct  deformity  of  the  jaw  like  a  tumor, 
whereas  acromegaly  enlarges  all  of  the  proportions  of  a 
bone.  Treatment  is  not  satisfactory,  as  a  rule.  Recently 
Horsley  has  obtained  amelioration  by  operating  and  remov- 
ing masses  of  bone. 


2.  Fractures. 

Definition. — A  fracture  is  a  solution,  by  sudden  force, 
of  the  continuity  of  a  bone  or  of  a  cartilage.  Clinically, 
under  this  head  are  placed  epiphyseal  separations  and  the 
tearing  apart  of  ribs  and  their  cartilages. 

Varieties  of  Fractures. — The  varieties  of  fractures  are 
as  follows : 

Simple  fracture  is  a  subcutaneous  fracture,  or  one  in  which 
no  open  wound  admits  air  to  the  seat  of  bone-injury.  This 
corresponds  to  a  contusion  of  the  soft  parts. 

Compound  fracture  is  an  open  fracture,  or  one  in  which 
an  open  wound  admits  air  to  the  seat  of  bone-injury.  This 
corresponds  to  a  contused  or  lacerated  wound  of  the  soft 
parts. 

A  primary  cojupoiuid  fracture  is  one  in  which  the  breach 
in  the  soft  parts  is  occasioned  at  the  time  of  the  accident, 
either  by  the  direct  violence  of  the  injury  or  by  the  forcing 
of  a  bone  or  bones  through  the  tissues. 

A  secondary  compound  fracture  is  one  in  which  the  breach 
in  the  soft  parts  occurs  after  the  accident,  either  from  slough- 
ing of  damaged  tissues,  from  ulceration  because  of  the  press- 
ure of  ill-adjusted  fragments,  or  from  the  forcing  of  a  bone 
or  bones  through  the  soft  parts  because  of  rough  handling, 
neglect,  or  the  tossing  of  delirium. 

Complicated  fracture  is  a  fracture  plus  the  complication 
of  a  joint-injury,  arterial  or  venous  damage,  or  injuiy  to 
the  nerves  or  soft  parts.  When  a  fractured  rib  injures  the 
lung  or  when  a  broken  vertebra  damages  the  cord  we  have 
a  complicated  fracture.  The  term  is  a  bad  one,  as  it  con- 
veys no  definite  meaning,  and  is  no  more  justifiable  than  it 
would  be  to  speak  of  "complicated  pneumonia"  or  "com- 
plicated typhoid,"  for  we  should  always  give  a  name  to  the 
complication  in  any  case.  It  should  be  remembered  that 
damage  to  the  soft  parts  not  sufficient  to  admit  air  to  the 
seat  of  fracture  does  not  make  the  case  a  compound  fracture, 
but  rather  complicates  a  simple  fracture.  Remember  also 
21 


322  MODERN  SURGE R  V. 

that  even  superficial  areas  of  tissue-destruction  must  be 
treated  antiseptically,  otherwise  absorption  of  pus-elements 
and  their  deposition  at  the  seat  of  injury  may  cause  diffuse 
osteomyelitis. 

Complete  fracture  is  that  which  extends  through  the  whole 
thickness  of  a  bone  or  entirely  across  it. 

Incomplete  fracture  is  that  which  extends  only  partially 
through  the  thickness  of  a  bone  or  only  partially  across  it. 

A  linear,  hair,  capillary,  or  fissured  fracture,  or  a  fissure, 
is  a  crack  in  a  bone  with  very  little  separation  of  the  edges. 
This  is  an  incomplete  fracture,  but  may  be  associated  with  a 
complete  break. 

A  green-stick,  hie koiy -stick,  zvillow,  or  bent  fracture  is  a 
true  incomplete  break.  It  is  commonest  in  the  forearm  or 
clavicle,  it  arises  from  indirect  force,  and  it  is  very  rare  after 
the  age  of  sixteen.  It  is  called  "  green-stick  "  because  the 
bone  breaks  like  a  green  stick  when  forced  across  the  knee, 
first  bending  and  then  breaking  on  its  convex  surface.  The 
bone,  being  compressed  between  two  forces,  bends,  and  the 
fibers  on  the  outer  side  of  the  curve  are  pulled  apart,  while 
those  on  its  concavity  are  not  broken,  but  are  compressed. 
In  correcting  the  deformity  the  fracture  is  apt  to  be  made 
complete.  The  permanent  bending  of  a  bone  without  a 
break  may  possibly  occur  in  youth. 

Depressionfracture  occurs  when  a  portion  of  the  thickness 
of  a  bone  is  driven  in  by  crushing.  Fracture  by  depression 
is  a  result  of  the  bending  in  of  a  bone  (as  the  parietal),  a 
fragment  breaking  off  from  the  side  toward  which  the  bone 
is  bending.  A  depressed  fracture  is  complete,  not  incom- 
plete, and  by  this  term  is  meant  an  injury  in  which  a  frag- 
ment of  the  entire  thickness  of  the  bone  is  driven  below  the 
level  of  the  surrounding  surface. 

Splinter-  and  Strain  fracture. — The  breaking  off  of  a 
splinter  of  bone  (splinter-fracture)  or  of  an  apophysis  con- 
stitutes an  incomplete  fracture.  A  strain  upon  a  ligament 
or  a  tendon  may  tear  off  a  shell  of  bone,  and  this  injury  is 
the  "  strain-fracture  "  of  Callender. 

Longitudinal  fracture  is  a  fracture  whose  line  is  for  a  con- 
siderable distance  parallel,  or  nearly  so,  with  the  long  axis 
of  the  bone.     This  is  common  in  gunshot-injuries. 

Oblique  fracture  is  a  fracture  whose  line  is  positively 
oblique  to  the  long  axis  of  the  bone.  Most'  fractures  from 
indirect  force  are  oblique. 

Transverse  fracture  is  a  fracture  whose  line  is  nearly  trans- 
verse to  the  long  axis  of  the  bone  (no  fracture  is  mathemati- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    323 

cally  transverse).  The  cause  is  often  but  not  invariably  direct 
force.  The  ''fracture  en  rave  "  (radish-fracture,  so  cahed  be- 
cause the  bone  brealvs  as  does  a  radish)  is  transverse  at  the 
surface,  but  not  within. 

Toothed  or  dentate  fracture  is  a  form  of  fracture  in  which 
the  end  of  each  fragment  is  irregularly  serrated  and  the  frag- 
ments are  commonly  locked  together ;  hence  the  deformity 
is  hard  to  correct.  Most  of  the  simple  fractures  from  direct 
force  are  serrated. 

Wedged-shaped,  V-shaped,  cnneated,  or  cuneiform  fracture 
("  fracture  oblique  spiroide,"  "  fracture  en  V "  of  Gosselin, 
"fracture  en  coin")  is  a  fracture  whose  line  has  the  shape  of 
a  V,  which  may  be  entire  or  may  want  the  point.  It  occurs 
at  the  articular  extremity  of  a  long  bone,  and  a  fissure  usu- 
ally arises  from  its  point  and  enters  the  joint.  If  complete, 
it  is  a  "comminuted  fracture." 

T-shaped  fracture  is  a  fracture  which  presents  a  transverse 
or  oblique  line  and  also  a  longitudinal  or  vertical  line.  It 
occurs  at  the  lower  end  of  either  the  humerus  or  femur,  the 
transverse  line  being  above,  and  the  vertical  line  (intercon- 
dyloid)  between,  the  condyles.  If  complete,  it  is  in  reality  a 
form  of  comminuted  fracture. 

Multiple  or  composite  fracture  is  a  condition  in  which  a 
bone  is  broken  into  more  than  two  pieces,  the  lines  of  frac- 
ture not  intercommunicating,  or  a  condition  in  which  two  or 
more  bones  are  broken.  Multiple  fractures  of  one  bone  are 
divided  into  double,  treble,  quadruple,  etc. 

Comminuted  fracture  is  a  condition  in  which  a  bone  is 
broken  into  more  than  two  pieces,  the  lines  of  fracture  inter- 
communicating. The  bone  may  be  broken  into  many  small 
fragments,  may  present  much  splintering,  or  may  actually  be 
ground  up. 

Impacted  fracture  is  one  in  which  one  fragment  is  driven 
into  the  other  and  solidly  wedged. 

Fracture  zvitJi  crushing,  or  penetration,  is  a  fracture  in  which 
one  bone  is  driven  into  the  other,  the  encasing  bone  bein":  so 
splintered  that  the  impacting  bone  is  not  firmly  held. 

Pathological,  spontaneous,  or  secondary  fracture  is  one 
occurring  from  a  very  insignificant  force  acting  on  a  bone 
rendered  brittle  by  disease. 

Ununited  fracture  is  a  term  used  to  designate  a  fracture 
in  which  bony  union  is  absent  after  the  passage  of  the  period 
normally  necessary  for  its  occurrence. 

Direct  fractiire  \s  one  occurring  at  the  primary  point  of  the 
application  of  force. 


324  MODERN  SURGERY. 

Indirect  fracture  is  one  occurring  at  a  point  distant  from 
the  area  of  the  primary  application  of  force. 

Stellate,  or  starred  fracture  (fracture  par  irradiation)  is  one 
in  which  several  fissures  radiate  from  a  center.  If  the  frac- 
ture be  complete,  it  is  in  reality  a  form  of  comminuted 
fracture. 

Helicoidal,  spiral,  or  torsion  fracture  is  a  fracture  resulting 
in  a  long  bone  from  twisting. 

Fracture  by  contre-coup  is  a  fracture  of  the  skull  which  is 
on  the  opposite  side  of  the  head  to  that  which  was  the  re- 
cipient of  the  force. 

Epiphyseal  Separation  or  Diastasis. — This  injury  occurs 
only  before  the  age  of  twenty-five  and  is  commonest  at  the 
lower  end  of  the  femur,  but  it  is  encountered  also  at  the 
lower  ends  of  the  tibia  and  radius  and  at  both  extremities  of 
the  humerus.  This  injury  induces  deformity,  which  is  often 
hard  to  reduce,  and  by  damaging  the  cartilage  may  retard  or 
inhibit  a  further  lengthening  by  growth  of  the  limb. 

Intra-uterine  fractures  are  usually  due  to  injuries  of  the 
mother's  abdomen  sustained  toward  the  end  of  pregnancy. 
Some  hold  that  they  can  arise  as  a  consequence  of  the  force 
of  violent  uterine  contractions.  Many  so-called  "  intra-ute- 
rine "  fractures  are  wrongly  named,  as  they  result  from  injury 
during  delivery.  In  sporadic  cretinism  (misnamed  congenital 
rickets)  the  bones  are  fragile  and  ill-ossified,  and  many  frac- 
tures may  occur  in  iitero. 

Designations  According  to  Seat  of  Fractures. — Fractures 
are  designated  also  according  to  their  anatomical  seats ;  for 
instance,  fracture  of  the  upper  third  of  the  shaft  of  the  femur, 
fracture  of  the  olecranon  process  of  the  ulna,  fracture  of  the 
middle  third  of  the  clavicle,  and  fracture  of  the  body  of  the 
lower  jaw.  Intra-articidar  fracture  is  one  extending  into  a 
joint;  intracapsidar  fracture  is  one  within  the  capsule  of 
either  the  shoulder-  or  hip-joint;  and  extracapsular  fracture 
is  one  just  without  the  capsule  of  either  the  shoulder-  or 
hip-joint. 

Causes  of  Fracture. — The  causes  of  fracture  are  (i)  ex- 
citing, immediate  or  direct,  and  (2)  predisposing  or  indirect. 

Exciting  causes  are  {a)  external  violence  and  {f)  muscu- 
lar action. 

External  violence  is  the  most  usual  exciting  cause.  Two 
forms  are  noted:  (i)  direct  violence  and  (2)  indirect  force. 

Fractures  from  direct  violence  occur  at  the  point  struck,  as 
when  the  nasal  bones  are  broken  with  the  fist.  In  such  frac- 
tures the  soft  parts  are  damaged ;  they  may  be  destroyed  at 


DISEASES  A'ND   IXJ CRIES   OF  BONES  AXD  JOINTS.    325 

once  in  part,  they  may  be  damaged  so  severely  that  a  portion 
sloughs,  or  they  may  be  damaged  so  slightly  that  they  do 
not  lose  vitality ;  hence  fractures  by  direct  violence  may  be 
compound  from  the  start,  may  become  so,  or  may  remain 
simple.  In  fractures  by  direct  force  discoloration,  due  to 
effused  blood,  usually  appears  at  the  point  struck  soon  after 
the  accident.  In  compound  fractures  by  direct  violence  the 
soft-part  injury  is  so  great  that  primary  tissue-union  cannot 
occur. 

Fractures  from  indirect  force  do  not  occur  at  the  point  of 
application  of  the  force,  but  at  a  distance  from  it,  the  force 
being  transmitted  through  a  bone  or  a  chain  of  bones,  as 
when  the  clavicle  is  broken  by  a  fall  upon  the  extended  hand. 
Such  fractures  tend  to  occur  in  regions  of  special  predilection. 
If  they  are  not  compound,  there  is  no  injury  of  the  surface 
over  the  fracture.  If  they  become  compound  by  projection 
of  fragments,  primary  union  may  still  occur.  Discoloration 
over  the  seat  of  fracture  is  usually  not  present  soon  after  the 
accident,  but  may  occur  later.  Discoloration  rapidly  appears 
in  soft  parts  at  the  point  where  the  force  was  first  applied. 

Muscular  action  is  a  rather  rare  cause.  Fractures  thus 
produced  result  from  sudden  or  violent  contraction.  Bones 
so  broken  are  usually  diseased.  Violent  coughing  may  frac- 
ture the  ribs  ;  attempting  to  kick  may  fracture  the  femur ; 
saving  one's  self  from  falling  backward  may  fracture  the 
patella ;  throwing  a  stone  may  fracture  the  humerus  ;  and 
sudden  extension  of  the  forearm  may  fracture  the  olecranon 
process  of  the  ulna. 

Predisposing  Causes. — There  are  two  classes  of  predis- 
posing causes,  namely:  (i)  physiological,  natural  or  normal, 
and  (2)  pathological  or  abnormal. 

Natural  Predisposing  Causes. — Under  this  head  is  consid- 
ered the  liability  to  fracture  possessed  by  individual  bones 
because  of  their  shape,  structure,  function,  or  position.  Those 
predispositions  occasioned  by  special  ages  are  also  consid- 
ered. In  youth  epiphyseal  separation  is  commoner  than  frac- 
ture, and  a  fracture  is  apt  to  be  incomplete.  Fractures  are 
commonest  between  the  ages  of  twenty-five  and  sixty.  From 
two  to  four  years  of  age  a  child  is  more  liable  to  fracture  than 
later,  because  he  is  then  learning  to  walk  (Malgaigne).  The 
bones  of  the  old  are  easily  broken,  but  the  normal  lack  of 
activity  of  the  aged  saves  them  from  more  frequent  injur\'. 
Thus  the  predispositions  of  age  are  in  part  due  to  habits  and 
in  part  to  bony  structure.  The  bones  of  the  young,  being 
elastic,  bend  considerablv  before  the\'  break  ;  the  bones  of 


326  MODERN  SURGERY. 

the  old,  being  brittle  and  inelastic,  break  easily,  but  do  not 
bend.  In  old  age  the  bones  become  lighter  and  more  porous, 
though  they  do  not  diminish  in  size.  An  absorption  takes 
place  from  the  interior  of  a  bone,  particularly  at  its  articular 
head,  the  medullary  canal  increases  in  size,  the  cancellous 
spaces  become  notably  larger,  and  portions  of  the  remaining 
bone  of  the  interior  show  a  fatty  change.  There  is  no  in- 
crease in  the  amount  of  mineral  salts  present,  as  was  long 
taught.  These  alterations  occur  earlier  in  women  than  in 
men.^  The  change  of  age  is  a  diminution  in  the  amount  of 
bone  present,  and  sometimes  a  fatty  change  in  a  portion  of 
what  remains.  If  the  atrophy  of  bone  is  other  than  that 
normal  to  senility,  it  constitutes  a  pathological  predisposing 
cause. of  fracture.  Normal  predisposing  causes  include  the 
person's  weight  (which  determines  the  force  of  a  fall),  mus- 
cular development,  habits,  sex,  occupation,  and  the  season 
of  the  year. 

Pathological  Predisposing  Causes. — Hereditary  fragility  is 
a  condition  commonest  among  women,  often  existing  in 
generation  after  generation,  and  in  which  condition  fractures 
occur  from  an  infinitely  slight  force.  There  exists  in  these 
cases  bony  rarefaction — in  fact,  a  premature  senility. 

Nervous  Diseases. — Bony  nutrition  is  dependent  on  the 
spinal  cord,  and  the  trophic  influence  is  probably  exerted 
through  the  posterior  nerve-roots  (Gowers).  In  diseases  of 
the  anterior  cornua  bony  growth  is  much  interfered  with ; 
in  diseases  of  the  posterior  columns,  as  in  locomotor  ataxia, 
a  true  bony  atrophy  bespeaks  trophic  disorder.  Syringo- 
myelia causes  brittleness  of  the  osseous  structures,  and  in 
paralysis  agitans  bones  are  thought  to  break  easily.  Trophic 
changes  may  occur  in  the  bones  of  the  insane,  most  com- 
monly when  insanity  is  linked  to  organic  disease.  About 
one-quarter  of  paretic  dements  show  undue  brittleness  or 
unnatural  softness  of  bone.^  The  bones  of  maniacs  are  fre- 
quently fragile.  In  asylum  practice  fractures  are  not  neces- 
sarily an  indication  of  abuse. 

Rickets. — Rickets  predisposes  to  fracture  because  of  altered 
bone-structure  and  the  great  liability  to  falls. 

Atrophy  of  Bone. — This  condition,  as  has  been  seen 
(p.  309),  is  normal  in  senility.  It  may  arise  from  want  of 
use,  as  is  observed  in  the  bedfast,  in  the  wasted  femur  of 
hip-joint  disease,  and  in  the  bones  of  a  stump.  It  may 
arise  from  pressure,  as  when  an  aneurysm  compresses  the 
ribs,  sternum,   or   vertebrae.     Among  other  of  the   patho- 

'  Humphrey  on  Old  Age.  ^  Spitzka's  Manual  of  Insanily. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.     327 

logical  predisposing  causes  are  to  be  mentioned  cancer, 
sarcoma,  and  hydatid  cysts  of  bone,  caries,  necrosis,  gout, 
scrofula,  syphilis,  mollities  ossium,  and  scurvy. 

Symptoms  of  Fracture. — History  of  an  Injury. — In 
spontaneous  fracture  there  may  be  no  record  of  violence ; 
for  instance,  when  a  bone  breaks  while  turning  in  bed.  In 
investigating  the  history,  not  only  seek  for  a  record  or  for 
evidences  of  violence,  but  try  to  determine  exactly  how  the 
accident  happened. 

A  sound  of  cracking  is  occasionally  audible  to  a  bystander 
at  the  time  of  the  injury.  The  patient  may  have  heard  it, 
but  very  rarely  does.  A  rupture  of  a  tendon  or  a  ligament 
produces  a  similar  sound. 

Pai)i  is  usually,  but  not  invariably,  present  (absent  often  in 
rickets).  Malgaigne  says  that  in  some  fractures  the  pain  is 
slight  or  absent,  in  others  it  is  torturing,  and  in  most  it  is 
severe  for  a  time  after  the  injury,  but  gradually  abates  unless 
reinduced  by  movement.  Pain  developed  at  the  time  of  the 
accident  is  far  less  important  as  a  symptom  than  that  which 
can  subsequently  be  produced  by  movement.  In  indirect 
fracture  there  is  an  area  of  pain  at  the  point  of  application 
of  the  force,  and  another  at  the  seat  of  fracture.  Pain  at  the 
seat  of  fracture  can  be  greatly  aggravated  by  pressure  or 
movement  and  is  rather  narrowly  localized. 

Deformity  or  alteration  in  length  or  outline  is  due  in  part 
to  swelling  and  in  part  to  a  change  in  the  mutual  relation  of 
the  fragments  (displacement).  The  deformity  of  swelling  is 
no  aid  to  a  diagnosis,  as  the  same  thing  occurs  in  contusion, 
and  it  often  hides  some  positive  symptomatic  distortion.  The 
swelling  is  due  first  to  blood  and  next  to  inflammatory  prod- 
ucts and  pressure-edema,  and  is  very  great  in  joint-frac- 
tures. The  deformity  of  displacement  may  be  produced  by 
the  violence  of  the  injury  (as  is  the  depression  in  a  skull- 
fracture),  by  the  weight  of  an  extremity  (as  is  the  falling  of 
the  shoulder  in  a  fracture  of  the  clavicle),  or  by  muscular 
action  (as  is  the  pulling  upward  of  the  superior  fragment  of 
a  fractured  olecranon  process). 

The  varieties  of  displacement  are  (i)  transverse  or 
lateral,  where  one  fragment  goes  to  the  side,  front,  or  back, 
but  does  not  overlap  the  other ;  (2)  angular,  the  bony  axis 
at  the  point  of  fracture  being  altered  and  the  fragments 
forming  with  each  other  an  angle ;  (3)  rotary,  one  fragment 
rotating  in  the  bony  circumference,  the  other  remaining 
stationary.  As  a  rule,  it  is  the  lower  fragment  which  turns 
on  its  long  axis,  rotating  with  it  the  limb  below  the  level  of 


328  MODERN  SURGERY. 

the  break ;  (4)  overlapping  or  overriding,  when  the  upper 
level  of  one  fragment  is  above  the  lower  level  of  the  other 
fragment.  It  is  usually  the  lower  fragment  which  is  drawn 
by  the  muscles  above  the  upper,  but  the  body-weight  and 
sliding  down  in  bed  may  push  the  upper  below  the  lower. 
In  overriding  the  ends  are  near  together  and  the  bones  are 
usually  in  contact  at  their  periphery.  It  is  obvious  that 
overlapping  is  associated  with  transverse  displacement,  as 
one  fragment  must  go  front,  back,  or  to  the  side ;  (5)  pene- 
tration or  impaction  is  when  one  fragment  is  driven  into  the 
other,  thus  producing  shortening ;  (6)  separation  of  the  two 
fragments  occurs  in  fracture  of  the  patella,  olecranon,  os 
calcis,  certain  articulations,  and  in  some  breaks  of  the  hume- 
rus when  the  arm  is  not  supported. 

It  is  important  to  remember  that  a  dislocation  may  produce 
displacement,  but  these  two  conditions  may  be  differentiated 
by  the  observation  that  the  displacement  of  fracture  tends 
to  reappear  after  complete  reduction,  while  that  of  dislocation 
does  not  reappear.  A  displacement  is  hard  to  detect  in  a  flat 
bone  and  when  one  of  two  parallel  bones  is  broken. 

Loss  of  function  may  be  shown  by  inability  to  move  the 
limb  because  of  the  break,  but  it  is  not  always  markedly 
present,  though  some  degree  invariably  exists.  It  is  slight 
in  "  green-stick  "  and  impacted  fractures  (unless  the  loss  of 
power  arises  from  pain  or  nerve-injury).  A  person  can  walk 
when  the  fibula  alone  is  broken,  and  likewise  in  some  cases 
of  intracapsular  fracture  of  the  femur,  and  can  often  put  the 
hand  on  the  head  in  fractured  clavicle  (Malgaigne).  The 
pain  of  any  injury  or  the  loss  of  power  from  nerve-trauma- 
tism  may  cause  loss  of  movement  in  the  limb.  This  symp- 
tom is  of  slight  diagnostic  value  in  most  fractures. 

Extravasation  of  Blood. — A  contusion  of  the  surface  ac- 
companied by  skin-abrasion  indicates  merely  the  point  of 
application  of  direct  external  violence.  If  contusion  is  exten- 
sive over  a  superficial  bone,  as  the  tibia  or  parietal,  after 
a  few  hours  it  often  simulates  fracture  by  presenting  a  soft, 
compressible  center  surrounded  by  a  ring  of  hard,  condensed 
tissues  and  coagulated  blood.  Direct  external  violence 
may  merely  occasion  ecchymosis,  and  in  fracture  from 
indirect  force  ecchymosis  may  occur  in  a  considerable  area. 
In  regard  to  this  symptom,  note  that  even  great  external 
violence  may  occasion  no  evident  contusion  or  ecchymosis, 
and  in  any  fracture  this  symptom  may  be  present  or  absent. 
In  old  people,  anemic  subjects,  and  drunkards,  extravasa- 
tion of  blood  is  frequently  marked  and  persistent.     By  sug- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    329 

gillation  is  meant  an  extrav^asation  of  blood  which  slowly 
invades  wide  areas  of  tissue  and  which  appears  at  the  sur- 
face only  after  some  time,  and  then  usually  as  a  yellowish 
discoloration.  Linear  ecchymosis  has  been  esteemed  by 
some  as  a  sign  of  fissure,  and  it  often  follows  fracture  of 
the  fibula.  Linear  ecchymosis  over  the  line  of  the  poste- 
rior auricular  artery  was  pointed  out  by  Battle  as  a  valuable 
sign  of  fracture  of  the  posterior  fossa  of  the  base  of  the 
cranium. 

Preternatural  mobility  is  a  most  important  symptom,  which 
is  pathognomonic  when  surely  found.  The  unbroken  bone 
is  nowhere  mobile  in  continuity.  By  preternatural  mobility 
is  meant  that  a  bone  is  mobile  in  continuity  or  that  there  is 
abnormality  in  the  direction  or  extent  of  joint-mobility.  In 
some  fractures  this  symptom  does  not  exist  (impacted,  green- 
stick,  and  locked  serrated  fractures) ;  in  others  it  cannot 
be  found  (fractures  of  tarsus,  carpus,  vertebral  bodies) ;  in 
others  it  is  difficult  to  obtain,  but  at  times  can  be  developed 
(fractures  near  or  into  many  joints).  To  develop  this  symp- 
tom, try,  when  the  case  admits,  to  grasp  the  fragments  and 
to  move  them  in  opposite  directions.  In  fractures  of  the 
shafts  of  the  femur  or  humerus  fix  the  upper  fragments  and 
carry  the  knee  or  elbow  in  various  directions  to  develop  bend- 
ing at  the  point  of  fracture.  In  fractured  clavicle  push  the 
shoulder  downward  and  inward.  In  fractures  of  either  bone  of 
the  forearm  grasp  the  opposite  bone  w^ith  four  fingers  of  each 
hand  and  make  pressure  on  the  suspected  bone  alternately 
with  either  thumb,  the  same  proceeding  being  used  in  fract- 
ures of  the  leg.  In  fractures  of  the  neck  of  the  femur  note 
the  rotation-arc  of  the  great  trochanter  (Desault).  In  fract- 
ures of  the  lower  end  of  the  radius  bend  the  hand  back,  and 
in  those  of  the  lower  end  of  the  fibula  evert  the  foot  (Mai- 
sonneuve).  In  seeking  preternatural  mobility,  remember  that 
the  elastic  ribs  when  being  forced  in  give  a  sense  of  bend- 
ing, and  that  the  fibula  at  its  middle  is  "  normally  flexible  " 
(Dupuytren).     Some  rachitic  bones  may  be  bent. 

Crepitus  or  erepitation  is  both  a  sensation  and  a  sound, 
which  indicates  the  grating  together  of  the  two  rough  sur- 
faces of  a  broken  bone.  This  symptom  is  of  great  value, 
but  it  is  not  always  present.  It  is  absent  in  locked  serrated 
fractures,  in  impacted  fractures,  in  cases  where  the  broken 
ends  cannot  be  approximated  (as  in  overlapping),  and  is  rare 
when  a  fractured  surface  is  against  the  side,  and  not  the 
broken  face,  of  the  other  fragment,  and  is  unusual  in  incom- 
plete fractures.     Crepitus  is  often  absent  in  epiphyseal  sepa- 


330  MODERN  SURGERY. 

ration,  in  softened  bones,  and  in  fractures  in  or  near  joints, 
and  it  may  be  prevented  from  occurring  by  blood-clot,  fascia, 
or  muscle  between  the  broken  surfaces.  The  grating  found 
in  tenosynovitis  must  not  be  mistaken  for  the  crepitus  of  fract- 
ure :  the  former  is  diffused,  large,  soft,  and  moist ;  the  latter 
is  limited,  small,  harsh,  and  dry.  The  clicking  of  an  inflamed 
or  eroded  joint  and  the  crackling  of  emphysema  must  also 
be  separated  from  bony  crepitus.  Crepitus  of  fracture  may 
be  present  at  one  moment,  but  absent  the  next.  It  is  often 
not  detected  during  the  time  swelling  is  marked,  and  cannot 
be  discovered  after  organization  of  the  callus  begins.  In  but 
few  fractures  is  it  needful  to  try  to  hear  crepitus  with  the 
naked  ear  or  with  a  stethoscope  upon  the  part,  but  in  doubt- 
ful cases  of  fractures  of  ribs  and  joints  it  should  be  tried. 

The  above-named  symptoms  are  known  as  "  direct."  There 
are  other  symptoms  known  as  "  circumstantial,"  such  as  the 
flow  of  blood  and  cerebrospinal  fluid  from  the  ear  after 
some  fractures  of  the  middle  fossa  of  the  skull ;  emphysema 
of  the  face  and  epistaxis  after  fractures  of  the  nasal  bones ; 
hemoptysis  and  emphysema  after  crushes  of  the  chest ;  dis- 
coloration following  the  line  of  the  posterior  auricular  artery 
after  fractures  of  the  posterior  fossa  of  the  skull ;  and  sub- 
conjunctival ecchymosis  after  fractures  of  the  anterior  fossa 
of  the  skull. 

Diagnosis. — Examine  as  soon  as  practicable  after  the 
injury — before  the  onset  of  swelling,  if  possible.  Expose  the 
part  completely,  taking  off  the  clothing,  if  necessary,  by  clip- 
ping it  along  the  seams.  Compare  the  part,  by  attentive 
scrutiny,  with  the  corresponding  part  on  the  opposite  side. 
If  any  deformity  be  present,  it  must  be  ascertained  that  it 
did  not  exist  before  the  accident.  If  the  nature  of  the  in- 
jury be  uncertain,  if  the  patient  be  very  nervous,  or  if  the 
part  be  acutely  painful,  it  is  better  to  give  ether  to  diagnos- 
ticate, and  set  and  dress.  In  injuries  of  the  elbow-joint 
always  anesthetize  before  examination,  unless  an  .r-ray  appa- 
ratus is  accessible  to  settle  the  diagnosis. 

A  fracture  is  distinguished  from  a  dislocation  by  its  preter- 
natural mobility,  its  easily  reduced  but  recurring  displace- 
ment, and  its  crepitus,  as  against  the  preternatural  rigidity, 
the  deformity,  difficult  to  reduce,  but  remaining  reduced,  and 
the  absence  of  crepitus  of  a  dislocation.  Further,  in  disloca- 
tion the  bone,  when  rotated,  moves  as  one  piece,  whereas  in 
fracture  it  does  not  so  move ;  in  dislocation  the  bony  pro- 
cesses are  felt  occupying  their  proper  relations  to  the  rest  of 
the  same  bone,  while  in  fracture  some  of  them  present  altered 


DISEASES  AND   nVJCR/ES   OF  BONES  AND  JOINTS.     33 1 

relations  ;  in  dislocation  the  head  of  the  bone  is  found  out  of 
its  socket,  but  in  fracture  it  is  felt  in  its  place.  It  is  impor- 
tant to  remember,  moreover,  that  a  fracture  and  a  dislocation 
may  occur  together,  and  that  the  rubbing  of  a  dislocated 
bone  against  an  articular  edge,  when  the  joint  has  been 
roughened  by  inflammation,  simulates  crepitus. 

Great  contusion,  by  inducing  extreme  tumefaction,  may 
mask  characteristic  deformity  and  obscure  crepitus.  When 
only  a  contusion  exists  pain  is  apt  to  be  diffused ;  but  if  a 
fracture  has  occurred,  the  pain  is  accentuated  at  some  narrow- 
spot.  In  many  cases,  before  he  can  give  a  certain  opinion, 
the  surgeon  must  wait  some  days  until  the  swelling  has 
largely  subsided.  In  such  a  case  it  is  best  to  assume  in  our 
treatment  that  a  fracture  exists  until  the  contrary  is  known. 
Combat  swelling  by  rest  and  the  use  of  lead-water  and  laud- 
anum  and  moderate  compression. 

In  impaction  the  diagnosis  is  difficult.  The  moderate  de- 
formity is  concealed  by  swelling ;  crepitus  and  preternatural 
mobility  do  not  exist  unless  the  fragments  are  pulled  apart, 
and  there  is  not  necessarily  much  loss  of  function.  A  con- 
clusion is  reached  largely  by  considering  the  nature,  direc- 
tion, and  extent  of  the  violence,  the  seat  of  the  pain,  and  by 
a  careful  study  of  the  most  minute  deformity.  Fissures  are 
hard  to  recognize.  They  rarely  present  any  evidence  of  their 
existence  except  a  localized  pain  and  possibly  a  linear  ecchy- 
mosis  appearing  after  a  few  days. 

In  green-stick  fractures  the  age,  the  deformity,  and  possi- 
bly crepitus  during  reduction,  help  in  the  diagnosis.  Epiphy- 
seal separations  are  diagnosticated  by  the  age,  the  preternat- 
ural mobility,  the  deformity,  the  situation  of  the  injuiy,  and 
the  absence  of  crepitus  or  the  presence  only  of  a  soft  crepitus. 
Fractures  are  often  hard  to  recognize  when  occurring  in  a 
group  of  bones  like  those  of  the  carpus  and  tarsus  (w  hich 
are  firmly  joined  by  dense  ligaments)  or  in  one  of  two  paral- 
lel bones.  There  is  not  always  a  certainty  that  a  fracture 
exists,  and  when,  after  a  careful  examination,  there  is  still  an 
uncertainty,  do  not  prolong  the  efforts  or  use  great  force,  but 
treat  the  case  as  a  fracture  until  a  cure  ensues  or  the  diag- 
nosis becomes  apparent. 

We  have  recently  had  added  to  our  resources  a  method 
of  incalculable  value  in  diagnosticating  fracture ;  that  is,  the 
use  of  the  force  known  as  the  A'-ray  or  the  Rontgen  ray.  We 
can  look  through  a  part  with  a  fluoroscope  and  see  the  bones 
as  shadows,  or  we  can  take  a  negative  of  the  shadows  and 
print  skiagraphs  from  it.      This  method  is  applicable  even 


332  MODERN  SURGERY. 

when  the  parts  are  swollen,  and  even  when  a  limb  is  clothed 

or  wrapped  in  dressings.  It  is  possible  to  obtain  a  picture  of 
a  fractured  skull  after  long  exposure ;  fractured  ribs  and  ver- 
tebrae can  be  detected ;  and  the  process  is  of  the  greatest 
use  in  detecting  fractures  of  the  limbs.  In  order  to  obtain 
certain  results  the  ;ir-rays  must  be  used  by  an  expert.  This 
method  should,  if  possible,  be  resorted  to  in  all  cases. 

Complications  and  Consequences. — Some  of  the  con- 
sequences and  complications  of  fractures  are — sloughing  of 
the  soft  parts,  thus  making  the  fracture  compound ;  extrav- 
asation of  blood,  causing  swelling  or  even  gangrene ;  rupt- 
ure of  the  main  artery  or  vein  of  the  limb ;  dislocation ; 
edema  from  pressure  of  extravasated  blood,  from  inflamma- 
tory exudation,  from  tight  bandaging,  from  thrombosis,  or, 
later,  from  the  pressure  of  callus  ;  stiffness  of  joints  from 
synovitis  with  adhesion,  from  displaced  fragments,  or  from 
intra-articular  callus ;  stiffness  of  tendons  from  adhesive  the- 
citis  or  from  the  presence  of  callus ;  paralysis  from  traumatic 
neuritis  or  the  pressure  of  callus  upon  nerve-trunks  ;  muscu- 
lar spasm ;  painful  callus  ;  exuberant  callus  ;  embolism  ;  fat- 
embolism  ;  pulmonary  congestion  ;  gangrene ;  shock  ;  septi- 
cemia; pyemia;  tetanus;  delirium  tremens;  urinary  retention ; 
extensive  laceration  of  the  soft  parts ;  rupture  of  large  nerves ; 
and  involvement  of  joints. 

Repair  of  Fractures. — Simple  Fracture. — In  a  simple 
fracture  the  bone  is  broken,  the  medullary  contents  are  lacer- 
ated, the  periosteum  is  torn,  and  the  overlying  soft  parts  are 
damaged  to  a  considerable  degree.  The  periosteum  is 
stripped  more  or  less  from  each  fragment,  but  it  is  rarely 
completely  torn  through,  an  untorn  portion  known  as  the 
periosteal  bridge  remaining.  The  amount  of  blood  effused 
is  usually  considerable,  and  it  forms  a  decided  prominence  at 
the  seat  of  fracture;  it  gradually  gathers  because  of  oozing, 
and  soon  clots.  This  clot  lies  in  the  medullary  canal,  be- 
tween the  fragments,  under  the  periosteum  at  the  ends  of  the 
fragments,  and  in  the  tissues  outside  of  the  periosteum. 
Very  rapidly  after  the  accident  the  damaged  parts  inflame 
(bone,  endosteum,  periosteum,  and  other  peri-osseous  struct- 
ures). The  inflammatory  exudate  enters  into  the  blood- 
clot  and  destroys  it.  The  clot  is  simply  dead  material  and 
in  no  way  contributes  to  repair,  and  it  is  replaced  by  em- 
bryonic tissue  which  quickly  becomes  vascularized  (granula- 
tion-tissue). 

This  granulation-tissue  passes  into  fibrous  tissue  and  then 
into    bone,  only  the   tissue    springing   from   the   periosteal 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.     333 

bridge  going  through  a  cartilaginous  stage.  The  mass  of 
new  tissue  around  and  between  the  bone-ends  is  called 
callus.  It  will  be  observed  that  the  name  is  applied  succes- 
sively to  embryonic  tissue,  granulation-tissue,  fibrous  tissue, 
and  bone.  Warren  tells  us  that  callus  has  no  well-defined 
outline,  and  "  involves  not  only  the  bone  and  periosteum,  but 
also  the  connective  tissue  and  some  of  the  surrounding  mus- 
cular tissue."  Even  a  few  days  after  the  injury  the  inflam- 
matory mass  is  much  firmer  than  follows  inflammation  in- 
volving other  structures,  and  the  bone-ends  are  deeply  im- 
bedded in  a  dense  mass. 

During  the  second  week  the  callus  is  greatly  strengthened 
by  the  formation  of  dense  fibrous  tissue  in  and  below  the 
periosteum,  of  less  dense  fibrous  tissue  outside  of  the  peri- 
osteum, and  of  cartilage  from  the  periosteal  bridge.  This 
new  tissue  contracts  decidedly.  During  the  third  week  ossi- 
fication begins  at  the  points  farthest  from  the  fracture,  and  in 
the  course  of  a  short  time  (from  three  to  six  weeks)  is  com- 
plete. The  ossified  callus  or  new  bone  is  spindle-shaped 
and  spongy. 

The  term  intermediate,  definitive,  or  permanent  callus  is 
used  to  describe  the  material  which  forms  between  the  fract- 
ured ends.  The  name  provisional  or  temporary  callus  is 
given  to  the  material  within  the  canal  (central  callus)  and 
external  to  the  bone  (ensheathing  callus).  The  amount  of 
provisional  callus  depends  directly  on  the  extent  of  sepa- 
ration and  the  amount  of  motion  between  the  fragments. 
It  is  Nature's  splint,  and  when  the  break  is  not  well  im- 
mobilized a  large  amount  is  formed.  The  greater  the 
amount  of  motion  the  larger  the  amount  of  provisional 
callus. 

The  ensheathing  callus  is  after  a  time  largely  absorbed, 
and  the  central  callus  in  the  course  of  a  long  time  may  also 
be  absorbed,  with  the  restoration  of  the  medullary  canal, 
although  this  latter  result  is  rare.  An  excessive  amount  of 
provisional  callus  may  ossify  nearby  tendons,  may  unite  two 
parallel  bones  (radius  to  ulna — tibia  to  fibula — a  rib  to  its 
neighbors),  may  block  a  joint  just  as  a  stone  in  the  crack  of 
a  door  will  block  a  door,  or  may  absolutely  abolish  a  joint. 
Fragments,  even  if  entirely  detached,  often  unite,  but  they 
may  be  surrounded  by  provisional  callus  ;  sometimes  they  do 
not  cause  trouble,  but  sometimes  they  lead  to  suppuration. 
It  takes  about  one  year  to  remove  the  temporary  callus.  If 
callus  does  not  get  beyond  the  fibrous  state,  there  exists 
that  form  of  ununited  fracture  known  as  "  fibrous  union." 


334  MODERN  SURGERY. 

The  definitive  or  permanent  callus  after  a  time  ceases  to  be 
porous  and  becomes  very  dense  bone. 

Compound,  fractures  without  much  destruction  or  bruis- 
ing of  soft  parts,  if  treated  antiseptically,  become  at  once 
simple  fractures  and  unite  as  such.  If  the  wound  is  not 
drained  and  asepticized,  septic  inflammation  occurs,  pus 
forms,  and  union  by  granulation  is  the  best  that  can  be 
obtained.  Compound  fractures  by  direct  violence  will  not 
heal  by  first  intention  because  of  the  extensive  loss  of 
vitality  of  a  large  area  of  the  soft  parts. 

Delayed  union  may  be  due  to  ill-health,  want  of  ap- 
proximation, etc.  (any  of  the  causes  mentioned  under  the 
heading  Non-union).  It  is  not  non-union,  but  may  eventuate 
in  non-union. 

Non-union  of  Fractures. — An  ununited  fracture  is  a 
fracture  in  which  the  fragments  are  not  held  together  by 
bone.  The  causes  are  local  and  constitutional.  The  local 
causes  2,x&  (i)  want  of  approximation  of  fragments  (a  frequent 
cause  of  want  of  approximation  is  interposition  of  soft  tissues, 
especially  muscle) ;  (2)  want  of  rest ;  (3)  want  of  blood- 
supply  (as  seen  in  the  heads  of  humerus  and  femur,  or 
when  a  nutrient  artery  is  torn,  or  when  a  thrombus  forms  in 
a  vein  near  the  fracture);  (4)  defective  innervation;  and  (5) 
bone-disease.  The  constitutional  causes  are  debility,  scurvy, 
Bright's  disease,  syphilis,  etc.  In  this  condition  the  broken 
ends  of  the  bone  round  off  and  the  medullary  canal  in  each 
fragment  becomes  closed  by  bone.  The  fragments  may  not 
be  held  together  by  any  material,  or  they  may  be  held  by  very 
thin  and  much-stretched  fibrous  tissue  {inembranous  union), 
or  by  strong,  thick,  fibrous  tissue  {ligamentous  or  fib7'ous 
union).  When  the  ends  of  the  bones  come  together,  are 
held  by  a  fibrous  capsule,  and  move  on  each  other,  there  is 
presented  a  false  joint  or  pseiidartlirosis.  Such  a  joint  may 
after  a  time  secrete  serous  fluid  for  lubrication. 

Vicious  union  is  union  with  great  deformity,  and  is  often 
productive  of  pain  and  loss  of  function.  It  arises  from  failure 
to  coaptate  the  fragments,  from  a  recurrence  of  displacement 
after  reduction,  or  from  yielding  of  callus  after  the  removal 
of  splints. 

Treatment  of  Fractures. — If  a  man  is  found  in  the 
street  with  a  fracture,  further  injury  must  be  prevented  by 
applying,  after  cutting  off  the  clothing  over  the  fracture,  some 
temporary  support.  If  an  ambulance  'or  patrol-wagon  can- 
not be  obtained,  move  the  patient  by  hand.  If  the  lower  ex- 
tremity be  involved,  an  improvised  stretcher  (a  board  or  a 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    335 

shutter)  is  placed  on  the  ground  beside  the  patient,  who  is 
placed  on  the  stretcher,  the  surgeon  lifting  the  injured  limb, 
and  the  patient  is  then  carried  to  the  hospital  and  carefully 
transferred  to  a  fracture-bed,  or,  if  taken  home,  to  a  small 
ordinary  bed,  a  board  being  placed  beneath  a  rather  hard  but 
even  mattress.  The  temporary  appliances  are  now  removed 
and  a  diagnosis  by  the  methods  before  given  is  proceeded 
with.  After  determining  the  injury  the  fragments  must  be 
adjusted.  This  should,  if  possible,  be  done  at  once,  because 
a  fracture  remaining  unreduced  may  become  compound,  the 
fragments  may  injure  important  structures,  and  they  are  sure 
to  cause  intense  pain.  Reduction  is  easily  effected  during 
shock,  as  the  muscles  are  in  a  state  of  relaxation.  If  there 
is  great  swelling,  reduction  may  be  impossible,  and  the  part 
must  then  be  supported  and  antiphlogistics,  sorbefacients, 
and  moderate  pressure  be  used,  avoiding  ice  and  tight  band- 
aging, which  predispose  to  gangrene.  Set  the  fracture  at 
the  first  possible  moment.  Velpeau's  axiom  was  to  reduce 
fractures  at  once,  regardless  of  pain,  spasm,  or  inflammation, 
as  reduction  is  their  cure. 

If  the  patient  is  very  nervous,  if  the  pain  is  severe,  or  if 
rigid  muscles  antagonize  the  efforts,  then  reduce  the  fracture 
under  anesthesia.  In  some  fractures  (as  those  of  the  clavicle) 
adjustment  is  effected  by  altering  the  position,  and  in  others 
(as  those  of  the  femur)  by  extension  and  counterextension ; 
in  some  by  tenotomy,  and  in  some  by  kneading,  bending, 
and  coaptation.  When  extension  is  employed,  always  en- 
deavor to  get  a  point  of  counterextension.  The  extension 
is  to  be  made  on  the  broken  bone  (if  possible,  in  the  axis  of 
the  bone),  and  is  to  be  steady,  not  jerky  nor  violent.  In 
some  cases  complete  reduction  is  impossible.  This  may  be 
due  to  spasm,  to  swelling,  to  the  catching  of  soft  parts 
between  the  fragments,  to  the  existence  of  a  loose  fragment, 
to  locking,  or  to  impaction.  An  impaction  by  rotation  can 
generally  be  released,  but  it  is  sometimes  undesirable  to 
reduce  it.  If  the  fragments  cannot  be  adjusted  without 
violence,  retain  them  in  the  best  attainable  position,  combat 
the  antagonistic  cause,  and  set  them  properly  as  soon  as 
possible. 

After  adjusting  the  fragments  they  must  be  maintained 
in  position  by  some  retentive  apparatus.  Avoid  pressure 
over  joints  or  bony  prominences,  and  particularly  guard 
against  tight  or  improper  bandaging.  The  circulation  in 
the  fingers  or  the  toes  must  be  observed  as  an  index  of 
circulation  in  the  limb ;  hence  leave  those  digits  exposed. 


336  MODERN  SURGERY. 

A  retentive  apparatus  should  prevent  the  re-occurrence  of  de- 
formity, and  not  be  itself  productive  of  pain  or  harm.  For 
the  first  few  days  of  treatment  of  a  simple  fracture  the  dress- 
ing is  removed  every  day,  to  make  sure  that  deformity  has  not 
recurred,  and  if  it  does  recur  the  fragments  must  at  once  be 
reset.  The  splints  should  be  padded  thoroughly,  especially 
when  over  joints  or  bony  prominences,  and  they  should,  if 
possible,  fix  the  joints  immediately  above  and  below  the 
break.     A  primary  roller  should  never  be  used. 

Some  surgeons  at  once  apply  an  immovable  dressing. 
This  proceeding  is  safe  in  simple  fractures  without  much 
displacement  or  soft-part  injury.  This  apparatus  is  used 
also  in  military  practice,  with  the  old  and  feeble  whom  we 
fear  to  put  to  bed,  with  the  young  who  are  very  restless,  and 
with  the  insane  or  the  delirious.  If,  however,  there  is  great 
deformity,  much  soft-part  injury,  or  marked  swelling,  im- 
movable dressings  may  induce  sloughing,  edema,  gangrene, 
or  faulty  union.  In  the  above-named  cases  use  splints  for 
the  first  few  days ;  then,  if  it  is  desirable,  the  immovable 
dressing  can  be  applied.  It  is  dangerous  to  keep  old  or 
feeble  persons  long  in  bed,  as  they  are  prone  to  develop 
bed-sores  and  hypostatic  pulmonary  congestion.  The  period 
for  the  artificial  retention  of  the  fracture  varies  with  the  seat 
of  the  fracture  and  the  age  and  the  condition  of  the  patient. 
Passive  motion  is  to  be  made  in  most  fractures  in  from  two  to 
three  weeks,  though  it  is  sometimes  made  earlier  to  prevent 
ankylosis.  Landerer  strongly  advocates  massage,  believing 
that  it  hastens  union  and  prevents  wasting.  He  applies  it  as 
soon  as  there  is  no  danger  of  the  callus  bending  (in  from 
eight  to  fourteen  days).  Massage  should  not  be  used  when 
great  edema  points  to  the  possibility  of  venous  thrombosis. 
The  movements  might  break  up  a  clot  and  cause  fatal  em- 
bolism.^ Very  early  massage  may  cause  fat-embohsm.  In 
fracture  of  the  patella,  Barker  and  many  others  believe  in 
wiring,  and  some  surgeons  advocate  the  same  procedure  in 
fracture  of  the  clavicle  and  fracture  of  the  tibia. 

The  plan  known  as  the  ambulatory  treatment  of  fractures 
of  the  lower  extremities  has  many  advocates.  Its  aim  is 
not  only  to  get  the  patient  about  on  crutches,  but  also  to 
cause  him  to  use  the  limb.  It  is  held  that  this  plan  of  treat- 
ment greatly  lessens  the  patient's  sufferings  and  actually 
favors  union  by  the  stimulation  of  walking.  Bardeleben, 
in  his  report  to  the  German  Surgical  Congress,  gave  the 
records  of  116  fractures  of  the  lower  extremity  thus  treated 

^  Cerne's  case,  in  Norniandie  nied. ;  Bull,  med.,  1895,  No.  44. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    337 


{jy  simple  and  12  compound  fractures  of  the  leg;  17  simple 
and  5  compound  fractures  of  the  thigh).  The  patients  were 
gotten  about  a  few  days  after  the  accident,  were  able  to 
attend  to  business,  had  excellent  appetites,  digested  their 
food  perfectly,  slept  well,  and  were  saved  from  muscular 
atrophy.  Pilcher  has  warmly  advocated  the  method.  It 
can  be  used  in  fractures  as  high  up 
as  the  middle  of  the  femur.  The 
apparatus  which  we  should  em- 
ploy in  the  ambulatory  treatment 
reaches  below  the  sole  of  the  foot, 
and  is  supported  firmly  above  the 
seat  of  fracture,  the  weight  of  the 
body  being  transferred  from  above 
the  fracture  to  the  firm  pad  below 
the  sole  of  the  foot  on  which  the 
patient  walks  (Fig.  66).  This  ap- 
pliance in  a  fractured  thigh  is  put 
on  about  one  week  after  the  inflic- 
tion of  the  injury.  While  the  pa- 
tient sits  on  the  ischial  tuberosities 
extension  is  made  upon  the  leg. 
The  seat  of  fracture  is  encircled 
with  a  thin  plaster  cast.  The  sole 
of  the  other  foot  is  raised  by  a 
cork  sole.  Albers  uses  plaster-of- 
Paris  strengthened  by  bits  of  wood, 
running  from  below  the  sole  of  the 
foot  to  the  iliac  crest,  when  he 
treats  a  fractured  thigh.  Krause 
says  in  fracture  of  the  ankle  carry 
the  dressing  to  the  head  of  the 
tibia ;  in  fracture  of  the  leg  carry 
it  to  the  middle  of  the  thigh  ;  in 
fracture  of  the  lower  end  of  the  femur  carry  it  to  the  pelvis.* 
Bradford  warmly  advocates  the  use  of  Thomas's  splint  often 
combined  with  plaster-of-Paris. 

Prevention  and  Treatment  of  Complications. — In  every 
case  of  fracture  feel  for  the  pulse  below  the  injury  in  order 
to  be  sure  the  artery  is  not  ruptured.  If  the  soft  parts 
are  badly  contused,  try  to  prevent  sloughing  by  rest,  re- 
laxation, and  lead-water  and  laudanum.  If  superficial  slough- 
ing occurs,  treat  antiseptically,  remembering  that  a  super- 
ficial excoriation   can  admit  bacteria  which,  carried  by  the 


Fig.   66. — Ambulatory   dressing 
(Harting). 


'  Centralbl.  f.  Chir.,  vol.  xxii.,  1895. 


22 


338  MODERN  SURGERY. 

blood  or  lymph,  may  infect  the  bones.  If  a  slough  leads 
down  to  the  fracture,  treat  the  case  as  one  of  compound  fract- 
ure. If  there  be  great  blood-extravasation,  the  danger  is 
gangrene,  and  the  foot  of  the  bed  is  to  be  elevated,  or  the 
extremity,  to  which  splints  and  bandages  are  to  be  loosely 
applied,  is  to  be  raised ;  lead-water  and  laudanum  is  applied 
if  there  be  much  inflammation,  and  cotton-wool  and  hot 
bottles  if  the  surface  be  cold.  If  a  bleb  forms,  it  is  to  be 
opened  with  a  needle  and  dressed  antiseptically.  If  gangrene 
occurs,  treat  by  the  usual  rules.  The  appearance  of  buUai 
when  the  circulation  is  good  does  not  mean  gangrene. 

Edema  may  be  due  to  tight  bandaging.  If  it  is  due  to 
phlebitis,  there  is  danger  of  pulmonary  or  cerebral  emboHsm. 
In  phlebitis  elevate  the  Hmb,  remove  all  constriction,  and 
employ  locally  tincture  of  iodin,  blue  ointment,  and  lead- 
water  and  laudanum,  and  internally  strong  stimulation.  In 
edema  due  to  weak  circulation  or  venous  relaxation  use 
daily  frictions  and  firm  bandaging.  If  the  fracture  involves 
a  joint,  carefully  adjust  the  fragments,  make  passive  motion 
early,  and  inform  the  patient  that  he  will  have  a  stiff  joint. 

A  dislocation  occurring  with  a  fracture  is  reduced  at  once 
if  possible.  To  do  this,  splint  the  limb  and  give  ether,  and 
try  to  reduce  while  the  limb  is  managed  with  the  splint  as 
a  handle.     If  this  fails,  it  is  best  to  incise  and  pull  the  sepa- 


FiG.  67. — Fracture-hook  (McBurney  and  Dowd). 

rated  end  in  place  by  the  hook  of  McBurney  and  Dowd  (Figs. 
67-69) ;  but  some  surgeons  say,  get  the  bones  in  the  best  pos- 
sible position,  set  them,  await  union,  and  then  treat  the  unre- 
duced dislocation.  Allis  is  often  able  to  reduce  a  dislocation 
accompanied  by  a  fracture.  He  uses  the  untorn  portion  of 
periosteum  as  a  hinge,  pulls  upon  the  fragment,  and  forces  it 
in  place  by  manipulation.  A  rupture  of  the  main  artery  of 
the  limb  presents  the  symptoms  of  absent  pulse  below  the 
rupture,  a  pulsating  tumor,  and  often  an  aneurysmal  thrill 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    339 

and  bruit.  This  condition  demands  that  the  surgeon  should 
apply  an  Esmarch  bandage,  cut  down  upon  the  tumor,  turn 
out  the  clot,  and  ligate  each  end  of  the  vessel.     If  these 


Fig.  68.— Fracture-hook  applied  at  base  of  acromion  process  (McBurney  and  Dowd). 

measures    fail    or   if  gangrene    appears,   amputate    at    once 
above  the  seat  of  the  fracture. 

Inflammation  is  to  be  treated  by  compression,  rest,  lead- 
water  and  laudanum,  and  later  by  a  50  per  cent,  ichthyol 
ointment.      Muscular    spasm   requires    morphin   internally, 


Fig.  69. — Fracture-hook  inserted  in  displaced  fragment  (McBurney  and  Dowd). 

firm  bandaging,  or  even  tenotomy.  Fat-embolism  is  treated 
by  stimulants  and  artificial  respiration.  Shock,  delirium 
tremens,  urinary  retention,  etc.  are  treated  according  to  the 
ordinary  rules  of  surgery. 

Treatment  of  Compound  Fractures. — It  must  first  be 
decided,  in  a  case  of  compound  fracture  of  a  limb,  if  ampu- 
tation is  necessary,  and  the  x-rays  are  of  great  value  in  de- 
termining the  condition  of  the  bones  in  a  crushed  part. 
Amputation  is  demanded  when  the  limb  is  completely 
crushed  or  pulpefied  through  its  entire  thickness ;  when 
extensive  pieces  of  skin  are  torn  off;  when  an  important 
joint  is  badly  splintered ;  w^ien  the  main  arter}^,  vein,  and 
nerve  are  torn  through ;  and  sometimes  when  there  is  vio- 
lent hemorrhage  from  a  deep-seated  vessel.  What  is  to 
be  done  is  to  some  extent  determined  by  the  patient's  age 
and  general  health.     In  a  healthy  young  person,  if  in  doubt, 


340 


MODERN  SURGERY. 


give  the  limb  the  benefit  of  the  doubt  and  try  to  save  it :  if 
the  artery  alone  is  ruptured,  cut  down  upon  it  and  tie  both 
ends;  if  the  nerve  is  severed,  suture  it;  if  a  joint  is  opened, 
drain  and  asepticize.  If  an  attempt  is  made  to  save  the  limb, 
be  ready  at  any  time  to  amputate  for  gangrene,  secondary 
hemorrhage  (if  re-ligation  at  original  point  and  compression 
high  up  fail),  extensive  cellulitis,  and  profuse  and  prolonged 
suppuration.^  When  it  is  determined  to  try  to  save  the  limb, 
the  part  must  be  cleansed  thoroughly  by  the  antiseptic 
method  (in  no  injuries  is  this  more  important).  The  frag- 
ments are  reduced,  the  ends  are  resected  if  necessary,  and 
are  usually  held  together  by  silver  wire,  copper  wire,  chro- 
micized  catgut,  or  kangaroo-tendon.  Thorough  through- 
and-through  drainage  is  established  and  tubes  are  inserted. 
The  extremity  is  put  in  a  proper  position,  the  damaged  area 
and  its  neighboring  parts  are  enveloped  in  corrosive-subli- 
mate gauze,  plaster  is  at  once  appHed  over  brackets  or  over  a 
well-padded  stick  of  wood,  and  in  the  plaster  a  trap-door  is 
cut  before  it  sets,  over  each  end  of,  and  around,  the  drainage- 
tube  (Fig.  70).     These  trap-doors  are  covered  with  corro- 


Fenestrated  plaster-of- Paris  dressing. 


sive-sublimate  gauze,  which  is  held  in  place  by  a  roller. 
The  drainage-tubes  are  usually  removed,  if  suppuration  does 
not  occur,  in  from  forty-eight  to  seventy-two  hours.  The 
wound  is  treated  as  any  other  wound.  A  compound  fract- 
ure of  the  skull  demands  trephining.     If  a  fracture  of  a  rib 

^  See  Howard  Marsh  on  "Fractures,"   in  Heaths  Dictionary  of  Practical 
Surgery. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    34 1 

is  compound  internally,  resect  the  rib ;  if  it  is  compound 
externally,  dress  antiseptically. 

Compound  fractures  may  be  followed  by  gangrene,  slough- 
ing, periostitis,  septicemia,  pyemia,  osteomyelitis,  necrosis, 
etc.  The  treatment  of  these  conditions  is  by  well-known 
rules. 

Treatment  of  Delayed  Union  and  Ununited  Fracture. — 
When  delayed  union  exists,  seek  for  a  cause  and  remove 
it,  treating  constitutionally  if  required,  and  thoroughly  im- 
mobilizing the  parts  by  plaster.  Orthopedic  splints  may  be 
of  value.  Use  of  the  limb  while  splinted,  percussion  over 
the  fracture,  and  rubbing  the  fragments  together,  thus  in 
each  case  producing  irritation,  have  all  been  recommended. 
Blistering  the  skin  with  iodin  or  firing  it  has  been  employed. 
If  the  case  be  very  long  delayed,  forcibly  separate  the  frag- 
ments and  put  up  in  plaster  as  a  fresh  break.  If  these  means 
fail,  irritate  by  subcutaneous  drilling  or  scraping,  or,  better, 
by  laying  open  the  parts  and  then  drilling  and  scraping  at 
many  places.  Buechner  advocates  the  induction  of  hyper- 
emia by  a  constricting  band,  just  as  Bier  induces  congestive 
hyperemia  for  tuberculous  areas.  At  first  the  constriction 
is  left  on  only  a  short  time,  but  the  period  is  lengthened 
every  day,  until  in  a  it.w  days  it  remains  almost  continuously 
day  and  night.  He  claims  that  ten  days  of  almost  contin- 
uous application  cures  most  cases.  Helferich  devised  this 
method  in  1887.  Lannelongue  and  Menard  inject  a  i  :  10 
solution  of  zinc  chlorid  between  the  fragments.  Leaving 
acupuncture-needles  in  for  days  is  approved  by  some,  and 
electropuncture  is  advocated  by  others.  Cases  of  ununited 
fracture  must  be  treated  by  excision  of  the  bony  ends  and 
fibrous  tissue,  securing  the  fragments  together  by  periosteal 
sutures,  by  pins,  by  screws  and  plates,  by  ivory  pegs,  by 
screws,  by  silver  or  copper  wire,  by  kangaroo-tendon,  by 
Senn's  bone-ferrules,  or  by  chromicized  catgut.  Delorme 
makes  an  incision,  removes  bone-splinters  and  fibrous  tissue, 
smooths  off  one  end,  forces  this  into  the  bored-out  medul- 
lary canal  of  the  other  fragment,  and  sutures  the  periosteum. 
Gussenbauer's  clamp  will  often  give  a  good  result,  and  was 
used  for  years  by  Billroth.  (See  Osteotomy  for  Ununited 
Fracture,  p.  482.) 

Treatmefit  of  Vicious  Union. — If  angular  deformity  results 
from  faulty  union,  it  can  be  corrected  by  moulding  while  the 
callus  is  soft.  If  the  callus  has  become  hard,  the  bone  can 
be  refractured.  If  faulty  union  occurs  with  overriding,  an 
osteotomy  can  be  performed. 


342  MODERN  SURGERY. 

Special  Fractures. — Nasal  Bones. — The  nasal  bones, 
because  of  their  situation,  are  often  broken.  The  commonest 
site  of  fracture  is  through  the  lower  third,  where  the  bones 
are  thin  and  lack  support.  The  fracture  may  be  compound 
externally  or  internally.  The  cause  is  direct  violence.  Dis- 
placement may  not  occur  at  all,  but  when  present  it  arises 
purely,  from  force,  and  never  from  muscular  action,  no  mus- 
cle being  attached  to  these  bones.  If  the  force  is  from  the 
front,  the  nose  is  flattened ;  if  from  the  side,  deflected  and  de- 
pressed. Displacement  is  soon  masked  by  swelling.  Crepitus 
can  sometimes  be  elicited  by  grasping  the  upper  part  of  the 
nose  with  the  fingers  of  one  hand  and  moving  it  below  from 
side  to  side  with  those  of  the  other  hand.  Preternatural  mo- 
bility is  valueless  as  a  sign,  because  of  the  natural  mobility 
of  the  cartilages.  Nose-breathing  is  difficult  because  of 
blocking  of  the  nostrils  by  blood-clot.  Diagnosis  is  almost 
impossible  when  deformity  is  absent. 

The  complications  that  may  be  noted  are  cerebral  concus- 
sion, brain-symptoms  from  implication  of  the  frontal  bone  or 
cribriform  plate  of  the  ethmoid,  and  extension  of  fracture  to 
the  superior  maxillary  or  lachrymal  bones.  Emphysema  of 
root  of  nose,  eyelids,  and  cheeks,  is  common,  and  means  either 
a  rent  in  the  mucous  membrane  of  Schneider  or  a  crack  in  the 
frontal  sinus.  There  may  be  much  discoloration  because  of 
subcutaneous  hemorrhage.  Epistaxis  is  usual,  and  is  sepa- 
rated from  the  epistaxis  in  fractures  of  the  base  of  the  skull  by 
the  facts  that  the  bleeding  in  the  first  condition  is  profuse,  is, 
as  a  rule,  soon  checked,  and  is  not  followed  by  an  ooze  of 
cerebrospinal  fluid;  whereas  in  the  second  condition  it  is  pro- 
fuse, continued,  and  followed  by  a  flow  of  cerebrospinal  fluid. 
Fracture  of  the  bony  septum  occasionally  complicates  nasal 
fractures,  and  deviation  of  the  cartilaginous  septum  often 
takes  place.     The  prognosis  is  usually  good. 

Treatment. — When  there  is  no  displacement,  or  when  a 
displacement  does  not  tend  to  be  reproduced  after  reduction, 
use  lead-water  and  laudanum  for  a  few  days  if  swelling  exists, 
but  employ  no  retentive  apparatus  of  any  kind.  Order  the 
patient  not  to  blow  his  nose  for  ten  days  and  to  syringe  it 
out  daily  with  a  solution  of  bicarbonate  of  sodium.  If  de- 
formity be  noted,  correct  it  at  once,  as  the  bones  soon  unite 
in  deformity.  If  the  attempts  at  reduction  are  very  painful, 
or  if  the  subject  be  a  child,  a  woman,  or  a  nervous  man,  give 
ether  or  spray  the  interior  of  the  nose  with  a  4  per  cent,  solu- 
tion of  cocain.  Reduction  is  effected  by  a  grooved  director 
or  steel   knitting-needle,  wrapped   in   iodoform    gauze   and 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    343 


Fig.  71. — Mason's  pin. 


passed  into  the  nostril ;  the  fragments  are  lifted  up  with  this 
instrument,  and  the  fingers  externally  mould  them  into  place. 
A  rubber  dilator  can  be  used  in 
reduction.  This  is  pushed  into 
the  nose  and  inflated  by  air  or 
water.  If  hemorrhage  is  mod- 
erate, check  it  with  cold ;  if  se- 
vere, by  plugging.  If  flattening 
tends  to  recur,  pass  a  Mason's 
pin  (Fig.  71)  just  beneath  the 
fragments,  through  the  line  of 
fracture  and  out  the  opposite  side. 
Steady  the  fragments  by  a  piece 
of  rubber  externally  caught  on 
each  end  of  the  pin,  or  with  figure- 
of-8  turns  around  the  ends  with 
silk.  Leave  the  pin  in  place  for 
five  days.  This  instrument  of  Mason's  is  a  sharp,  strong, 
nickel-plated  pin,  with  a  triangular  point. 

If  a  lateral  deformity  tends  to  recur,  hold  a  compress  over 
the  fracture  or  fix  a  moulded-rubber  splint  over  the  nose  by 
a  piece  of  rubber-plaster  one  and  a  half  inches  broad  and 
long  enough  to  reach  well  across  the  face,  and  use  compres- 
sion for  ten  days.  In  neither  of  the  above  cases  is  the  nose 
to  be  blown,  but  in  both  cases  it  is  to  be  syringed  daily.  In 
both  cases,  after  dressing,  if  the  swelling  be  marked,  use  lead- 
water  and  laudanum.  In  fractures  rendered  compound  by 
tears  in  the  mucous  membrane  irrigate  with  normal  salt 
solution  or  boracic-acid  solution,  holding  the  head  so  that 
the  solution  will  not  run  into  the  mouth ;  plug  with  iodo- 
form gauze  around  a  small  rubber  catheter,  which  instrument 
permits  nose-breathing ;  carefully  remove  the  gauze  daily 
and  syringe.  In  fractures  compound  externally  cleanse  anti- 
septically  externally,  and  dress  with  a  film  of  cotton  soaked 
in  iodoform  collodion  or  com- 
pound tincture  of  benzoin,  or 
apply  sterile  gauze.  Fractures 
of  the  bony  septum,  if  showing 
a  tendency  to  reproduction  of 
deformity,  require  packing  as 
above  explained,  or  the  use  of  a 
special  splint  (Fig.  72).  Fractures  of  the  nasal  cartilages  are 
to  be  pinned  in  place.  Fractures  of  the  nose  are  entirely 
united  in  from  ten  to  twelve  days. 

Fractures   of    the    Lachrymal    Bone. — The    lachrymal 


Fig.  72. — Jones's  nasal  splint. 


344  MODERN  SURGERY. 

bone  may  be  broken  when  the  nasal  bones,  a  superior 
maxillary  bone,  or  the  lateral  plate  of  the  ethmoid  are 
fractured. 

Treatment. — Treat  the  chief  injury,  which  is  the  fracture 
of  the  other  bone.  Maintain  the  patency  of  the  lachrymal 
duct  by  passing  frequently  a  clean  probe. 

Fractures  of  the  Superior  Maxillary  Bone. — Although 
a  fragile  bone,  the  superior  maxillary  is  rarely  broken 
except  through  the  alveolar  border.  It  may  be  broken 
by  transmitted  force  from  blows  on  the  chin,  or  on  the 
head  when  the  chin  is  fixed ;  but  direct  violence  is  the 
usual  cause,  and  the  wall  of  the  antrum  may  be  crushed  in. 
Comminution  is  the  rule,  and  the  injury  is  often  compound. 
These  fractures  induce  great  swelling,  pain,  and  inability  to 
chew;  mobility  and  crepitus  may  be  detected.  Deformity 
is  due  to  the  breaking  force,  and  not  to  the  action  of  any 
muscle.  When  a  portion  of  the  alveolar  arch  is  fractured,  as 
may  occur  in  pulling  teeth,  the  fragment  is  depressed  back- 
ward, and  there  exist  irregularity  of  the  teeth  (some  of  which 
may  be  loosened)  and  inability  to  chew  food.  Fracture  of 
the  nasal  process  is  apt  to  injure  the  lachrymal  duct.  When 
the  antrum  is  broken  in  there  are  great  sinking  over  the  fract- 
ure, depression  of  the  malar  bone,  and  emphysema.  Trans- 
verse fracture  of  the  upper  part  of  the  body  of  the  bone  may 
cause  no  deformity.  The  force  sufficient  to  break  the  supe- 
rior maxillary  bone  is  so  great  that  fractures  of  other  bones 
almost  certainly  occur,  and  concussion  of  the  brain  not  infre- 
quently exists.  Injury  of  the  infraorbital  nerve  is  not  unusual, 
causing  pain,  numbness,  or  an  area  of  anesthesia  involving 
one-half  of  the  upper  lip,  the  ala  of  the  nose,  and  a  triangle 
whose  base  is  one-half  the  upper  lip  and  whose  apex  is  the 
infraorbital  foramen.  There  is  also  loss  of  sensation  in  the 
gums  and  upper  teeth  of  the  injured  side.  Fractures  of  the 
superior  maxillary  bone  occasionally  induce  fierce  hemor- 
rhage from  branches  of  the  internal  maxillary  artery,  and  if 
this  occurs,  watch  out  for  secondary  hemorrhage  (these  ves- 
sels being  in  firm  canals). 

Treatment. — If  the  fracture  does  not  implicate  the  alveolus, 
or  if  no  deformity  exists,  apply  no  apparatus,  but  feed  the 
patient  on  liquid  food  for  four  weeks.  Reduce  deformity,  if 
it  exists,  by  inserting  a  finger  in  the  mouth.  If  the  antrum 
is  broken  in,  put  the  thumb  in  the  mouth  and  push  the  malar 
bone  up  and  back.  In  certain  cases  of  deformity  make  an 
incision  at  the  anterior  border  of  the  masseter  muscle,  insert 
a  tenaculum  or  aneurysm-needle,  and  pull  the  bone  into  place 


DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS.    345 

(Hamilton).  If  the  malar  bone  or  malar  process  is  driven 
into  the  antrum,  Weir  tells  us  to  incise  the  mucous  mem- 
brane above,  and  external  to,  the  canine  tooth  of  the  upper 
jaw,  break  into  the  antrum  with  a  bone  gouge,  insert  a 
steel  sound,  lift  out  the  malar  bone,  and  pack  the  antrum 
with  gauze.  Loose  teeth  are  not  to  be  removed  :  they  are 
pushed  back  into  place  and  held  by  wiring  them  to  their 
firmer  neighbors.  Hemorrhage  is  arrested  by  cold  and 
pressure.  If  hemorrhage  is  dangerously  profuse  or  pro- 
longed, tie  the  external  carotid. 

If  the  line  of  the  teeth,  notwithstanding  the  wiring,  is  not 
regular,  mould  on  an  interdental  splint.  The  usual  splint  for 
the  upper  jaw  is  the  lower  jaw  held  firmly  against  it  by  the 
Gibson,  the  Barton,  or  the  four-tailed  bandage.  Ever}^  second 
day  remove  the  bandage  and  wash  the  face  with  ethereal 
soap.  The  patient,  who  is  ordered  not  to  talk,  is  to  live  on 
Hquid  food  administered  by  pouring  it  into  the  mouth  back 
of  the  last  molar  tooth  by  means  of  a  tube  or  a  feeding-cup. 
Never  pull  a  tooth  to  get  a  space,  but  if  a  tooth  is  lost,  utilize 
its  space  for  this  purpose.  After  ever}^  meal  wash  out  the 
mouth  with  chlorate-of-potassium  or  boracic-acid  solution  to 
prevent  foulness  and  the  digestive  disorders  it  may  induce. 
Leave  off  the  dressings  in  five  weeks,  and  let  the  patient 
gradually  return  to  ordinary  diet. 

In  fractures  compound  externally  do  not  remove  frag- 
ments, antisepticize,  arrest  bleeding  as  far  as  possible  by 
ligature,  by  pressure,  or  by  plugging,  wire  the  fragments  if 
feasible,  dress  with  gauze,  and  wash  the  mouth  with  great 
frequency.  Fractures  compound  internally  are  treated  as 
simple  fractures,  except  that  the  mouth  is  washed  more 
frequently. 

The  malar  bone  is  rarely  broken  alone.  Hamilton  says 
no  uncomplicated  case  is  on  record.  The  malar  is  a  strong 
bone  resting  on  a  fragile  support,  and  hence  it  can  be  used 
as  a  wedge  to  break  other  bones  and  yet  itself  be  unfract- 
ured.  The  cmisc  of  fracture  is  violent  direct  force.  A 
fracture  of  the  orbital  surface  of  this  bone  causes  subcon- 
junctival hemorrhage  like  that  encountered  in  fracture  of 
the  base  of  the  skull.  Protrusion  of  the  eye  may  result 
either  from  hemorrhage  or  from  crushing  in  of  the  malar 
bone.     Chewing  is  apt  to  cause  pain. 

Treatment. — If  no  deformity  exists,  there  is  practically 
nothing  to  be  done.  If  deformity  exists,  try  to  correct  it  as 
in  fractures  of  the  superior  maxillary.  As  these  cases  are 
almost  invariably  complicated  by  breaks  of  the  upper  jaw, 


346  MODERN  SURGERY. 

they  are  treated  in  the  same  manner  as  the  latter  injury. 
The  union  is  complete  in  three  weeks. 

Fracture  of  the  zygomatic  arch  is  very  rare.  The 
causes  are  (i)  direct  violence;  (2)  indirect  force  (from  depres- 
sion of  the  malar) ;  and  (3)  forcing  of  foreign  bodies  through 
the  mouth.  Direct  violence  is  the  usual  cause.  Direct  vio- 
lence causes  inward  displacement,  and  indirect  force  may 
cause  outward  displacement.  The  usual  seat  of  fracture  is 
at  the  smallest  portion  of  the  process — that  is,  on  the  tem- 
poral side  of  the  temporomalar  suture  (Matas).  The  symp- 
toms are  pain,  ecchymosis,  swelling,  displacement,  and  dif- 
ficulty in  moving  the  jaw  (because  of  injury  to  the  masseter). 

Treatment. — In  simple  fracture  give  ether  and  try  to  push 
the  arch  in  place.  Many  surgeons  do  not  make  an  incision, 
as  depression  will  do  no  harm  and  the  functions  of  the  jaw 
will  be  restored.  Simply  dress  with  compress,  adhesive 
strips,  and  crossed  bandage  of  the  angle  of  the  jaw  (Fig.  267). 
Union  will  take  place  in  three  weeks.  Matas  ^  advises  that 
an  anesthetic  be  administered  and  the  parts  be  asepticized. 
A  long  semicircular  Hagedorn  needle  is  threaded  with  silk, 
is  entered  one  inch  above  the  middle  of  the  displaced  frag- 
ment, is  passed  well  into  the  temporal  fossa,  and  is  made  to 
emerge  half  an  inch  below  the  arch.  The  silk  is  used  to 
pull  a  silver  wire  through  around  the  fracture,  and  this  wire 
is  employed  to  pull  the  bone  into  po.sition.  A  firm  pad  is 
applied  externally  and  the  wire  is  twisted  over  the  pad. 
Matas  dresses  antiseptically,  and  on  the  ninth  or  tenth  day 
removes  the  wire,  splint,  and  dressings  permanently. 

Fractures  of  the  inferior  maxillary  bone  may,  and  most 
usually  do,  affect  the  body,  although  they  occasionally  occur 
in  the  rami.  Any  part  of  the  body  may  be  fractured,  the  most 
usual  seat  being  near  the  canine  tooth  or  a  little  external  to 
the  symphysis  (Pick).  A  portion  of  alveolus  may  be  broken 
off.  In  fractures  of  the  ramus  either  the  angle,  the  condyloid 
neck,  or  the  coronoid  process  may  be  broken.  In  fractures 
of  the  body  the  posterior  fragment  generally  overrides  the 
anterior.  Fractures  of  the  lower  jaw  are  often  multiple 
and  are  almost  always  compound,  because  the  oral  mucous 
membrane  and  alveolar  periosteum  are  torn.  The  cause  is 
usually  direct  violence.  Indirect  violence  (lateral  pressure) 
may  fracture  the  body  anteriorly.  Fractures  near  the  angle 
are  always  due  to  direct  violence.  Indirect  violence  may 
fracture  the  condyle  (falls  on  the  chin),  and  so  may  direct 
violence.     Fractures  of  the  coronoid  are  very  rare,  and  they 

1  New  Oi'leans  Med.  and  Surg.  Jour.,  Sept.,  1 896. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    347 


arise  from  great  direct  violence  (usually  gunshot-wound  or 
some  other  penetrating  force). 

Symptoms. — In  fracture  of  the  body  preternatural  mobility 
and  crepitus  generally  exist.  There  is  bleeding  because  of 
laceration  of  the  gums  ;  saliva  dribbles  constantly ;  the  jaw 
is  supported  by  the  hand  ;  great  pain  exists  (possibly  from  in- 
jury of  the  nerve) ;  and  deformity  is  present,  shown  by  inequal- 
ity of  the  teeth  if  the  fracture  is  anterior  to  the  masseter,  the 
anterior  fragment  going  downward  and  backward  and  the 
posterior  fragment  going  upward  and  forward.  The  down- 
ward displacement  is  due  to  muscular  action  (action  of  the 
digastric,  geniohyoid,  and  geniohyoglossus).  The  backward 
displacement  is  due  to  the  violence.  The  temporal  muscle 
draws  the  posterior  fragment  up  and  to  the  front.  In  fract- 
ure of  the  neck  of  the  condyle  the  jaw  is  drawn  toward  the 
injured  side,  and  the  condyle  goes  inward  and  forward  by  the 
action  of  the  external  pterygoid.  In  fracture  of  the  coronoid 
process  the  temporal  pulls  the  small  fragment  up. 

Complications. — The  complications  are — digestive  disorders 
and  diarrhea  from  swallowing  foul  discharges  ;  loosening  of 
the  teeth ;  loosened  teeth  be- 
tween fragments ;  bleeding 
(usually  only  oozing  from 
the  gums,  but  there  may  be 
hemorrhage  from  the  infe- 
rior dental) ;  and  suppura- 
tion. Necrosis  may  follow 
these  fractures. 

Treatment.  —  Remove  a 
tooth  if  between  fragments, 
but  replace  it  in  its  socket 
after  reducing  the  fracture. 
Correct  deformity.  Push  in 
loose  teeth  and  put  back  de- 
tached ones.  Wash  out  the 
mouth  with  hot  water  to  clean 
it  and  to  check  bleeding.  If 
bleeding  is  very  severe,  com- 
press the  carotid  for  a  time.  The  fracture  can  be  dressed 
with  a  pad  of  lint  over  the  chin  and  Hamilton's  four-tailed 
bandage  (Fig.  ']^^  ;  or  put  on  a  splint  of  paste-board,  felt,  or 
gutta-percha  (cut  as  shown  on  PI.  5,  Figs.  3,  4)  moulded  to 
the  part,  padded  with  cotton,  and  held  in  place  by  a  Barton's 
or  a  Gibson's  bandage  (Figs.  264,  266).  If  apposition  of  the 
fragments  cannot  be  maintained  by  the  above  methods,  fasten 


Fig.  73. — Hamilton's  bandage. 


348 


MODERN  SURGERY. 


the  teeth  together  with  wire,  wire  the  fragments  themselves 
together,  or  have  a  dentist  apply  an  interdental  splint  (Fig.  74). 
The  patient  is  to  be  fed  on  liquid  food  (see  Fracture  of  the 
Upper  Jaw,  p.  345),  the  mouth  is  to  be  washed  out  frequently, 
and  the  dressings  are  to  be  changed  every  second  day.  The 
union  is  complete  in  five  weeks.     Though  these  fractures 


Fig.  74. — Interdental  splints. 


are  usually  compound,  they  do  not  endanger  life.  If  they 
are  compound,  wash  the  mouth  often  with  a  solution  of 
boracic  acid  or  of  chlorate  of  potassium. 

Fractures  of  the  Hyoid  Bone. — These  fractures  are  rare 
injuries,  and  are  caused  by  hanging,  by  the  throat  being 
grasped  by  an  antagonist,  and  by  falls  in  which  the  neck 
strikes  some  obstacle.  If  the  bone  breaks  by  throttling,  it  is 
its  body  which  fractures  (indirect  force).  Fractures  by  mus- 
cular action  are  most  unusual. 

Symptoms. — The  symptoms  are — a  sensation  of  something 
breaking;  bleeding  from  the  mouth  if  the  mucous  mem- 
brane be  lacerated;  pain,  which  is  worse  on  opening  the 
jaws  or  on  moving  the  head  or  tongue ;  difficulty  in  swal- 
lowing (dysphagia) ;  muffled,  hoarse,  or  absent  voice ;  swell- 
ing, and  frequently  ecchymosis,  of  the  neck.  There  are 
observed  occasionally,  though  rarely,  harsh  cough  and  dysp- 
nea, irregularity  of  bony  contour,  and  crepitus.  Always 
look  into  the  mouth  and  see  if  there  can  be  detected  ecchy- 
mosis or  laceration  of  the  mucous  membrane  or  projection 
of  a  bony  fragment.  The  displacement  is  due  to  the  middle 
constrictor  of  the  pharynx  contracting.  This  fracture  may 
destroy  life. 

Treatment. — For  dyspnea  be  ready  to  perform  intubation 
or  tracheotomy  at  a  moment's  notice.  Edema  of  the  glottis 
is  a  great  danger.     Try  to  restore  the  fragments  with  one 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    349 

hand  externally  and  with  a  finger  in  the  mouth.  Put  the 
patient  to  bed  and  have  him  He  back  upon  a  firm  rest  so 
that  his  shoulders  are  elevated.  His  head  is  to  be  thrown 
between  extension  and  flexion,  a  pasteboard  splint  or  collar 
is  moulded  on  the  neck,  and  a  bandage  is  applied  around 
forehead,  neck,  and  shoulders  to  keep  the  head  immobile. 
The  patient  must  not  utter  a  word  for  a  week ;  he  must  at 
first  be  fed  by  enemata,  and  then  for  some  time  on  liquid 
diet  which  is  given  through  a  tube  early  in  the  case. 
Endeavor  to  control  the  cough  by  opiates.  A  fractured 
hyoid  bone  requires  about  four  weeks  to  unite. 

Fracture  of  laryngeal  cartilages  is  caused  by  direct 
violence,  as  throttling,  blows,  or  kicks.  It  is  rare  in  young 
persons,  and  is  commonest  when  the  cartilages  have  begun 
to  ossify.  It  is  a  very  grave  injury  (80  per  cent,  die),  death 
arising  from  obstruction  to  the  entrance  of  air. 

Symptoms. — The  symptoms,  which  are  severe,  are  pain, 
aggravated  by  attempts  at  swallowing  or  speaking ;  swelling, 
ecchymosis  it  may  be,  and  emphysema  of  the  neck  ;  cough  ; 
aphonia ;  intense  dyspnea ;  and  bloody  expectoration  if  the 
mucous  membrane  is  ruptured.  There  can  be  detected  in- 
equality of  outline  (flattening  or  projection)  and  perhaps 
moist  crepitus.  The  usual  seat  of  the  injury  is  the  thyroid 
cartilage. 

Treatment. — Cases  without  dyspnea  require  quiet,  avoid- 
ance of  all  talking,  feeding  with  a  stomach-tube,  compresses 
and  adhesive  strips  over  the  fracture,  and  remedies  to  quiet 
cough.  Be  ready  to  operate  at  any  moment.  In  most 
cases  dyspnea  exists,  due  to  projection  of  the  fragments  or 
submucous  extravasation.  When  there  is  dyspnea,  emphy- 
sema, or  spitting  of  blood,  at  once  practise  intubation,  or,  if 
unable  to  do  this,  open  the  larynx  or  trachea  below  the  seat 
of  fracture.  If  laryngotomy  or  tracheotomy  is  done,  try  to 
restore  displaced  fragments.  If  the  fragments  will  not  stay 
reduced,  introduce  a  Trendelenburg  cannula  or  a  tracheot- 
omy-tube around  which  gauze  is  packed.  Take  out  the 
packing  in  four  days,  and  remove  the  tube  as  soon  as  the 
patient  breathes  well,  when  the  opening  is  allowed  to  close. 
In  these  fractures  feed  with  a  stomach-tube  and  keep  the 
patient  absolutely  quiet.    Union  takes  place  in  four  weeks. 

Fracture  of  the  Ribs. — The  ribs,  owing  to  their  shape, 
elasticity,  and  mode  of  attachment,  readily  bend  and  as  read- 
ily recover  their  shape,  thus  standing  considerable  force  with- 
out breaking.  Notwithstanding  these  facts,  the  situation  of 
the  ribs  so  exposes  them  that  in  16  per  cent,  of  all  cases  of 


350  MODERN  SURGERY. 

fractures  noted  by  Gurlt  these  bones  were  involved.  In  chil- 
dren this  injury  is  rare  and  is  most  usually  incomplete;  it  is 
common  in  adults  and  the  aged,  and  in  them  is  generally 
complete.  It  is  more  frequent  among  men  than  among 
women.  The  ribs  commonly  broken  are  from  the  fifth  to  the 
ninth,  the  seventh  being  the  one  that  usually  suffers.  Fract- 
ure of  the  first  rib  alone  is  an  excessively  rare  accident.  The 
eleventh  and  twelfth  ribs  are  seldom  broken.  A  rib  may  be 
broken  in  several  places,  and  several  ribs  are  often  broken  at 
the  same  time.  Fracture  of  a  single  rib  is  not  nearly  so  com- 
mon as  fracture  of  several  ribs.  These  fractures  may  be 
compound  either  through  the  skin  or  through  the  pleura,  a 
damaged  lung  permitting  pneumothorax.  Compound  fract- 
ures are  very  rare,  however,  except  from  bullet-wounds. 

Causes. — Direct  force,  as  buffer  accidents,  blows  with  heavy 
instruments,  or  being  jumped  on  while  recumbent,  may  pro- 
duce these  injuries.  A  fracture  from  direct  violence  occurs 
at  the  point  struck,  and  the  ends,  projecting  inward,  may 
damage  the  viscera.  Indirect  force,  as  great  pressure  or 
blows  which  exaggerate  the  natural  bony  curves,  tends  to 
produce  fractures  near  the  middle  of  the  ribs  or  in  front  of 
their  angles  and  to  force  the  ends  outward.  A  number  of 
ribs  are  apt  to  be  broken.  Muscular  action,  as  in  coughing 
or  parturition,  occasionally,  but  very  rarely,  is  a  cause. 

Symptoms. — In  connection  with  the  history  of  the  accident 
the  symptoms  are — acute  localized  pain  (a  stitch)  on  breath- 
ing, increased  by  pressure  over  the  injury,  pressure  backward 
over  the  sternum,  cough,  and  forcible  inspiration  or  expira- 
tion ;  respiration  is  largely  diaphragmatic,  the  patient  en- 
deavoring to  immobilize  the  injured  side;  cough  is  frequent 
and  is  suppressed  because  of  pain.  Crepitus  is  often  but  not 
invariably  found.  It  is  sought,  first,  by  resting  the  palm  over 
the  seat  of  pain  while  the  patient  takes  long  breaths  ;  second, 
by  placing  a  thumb  before  and  one  behind  the  seat  of  pain 
and  making  alternate  pressure ;  and  third,  by  auscultation.  It 
should  be  remembered  that  incomplete  fractures  are  the  rule 
in  children  ;  hence  in  them  do  not  expect  crepitus.  Deform- 
ity is  usually  trivial  unless  several  ribs  are  broken,  because 
shortening  cannot  occur  and  the  intercostal  attachments  pre- 
vent vertical  displacement.  Preternatural  mobility  may  occa- 
sionally be  elicited,  when  the  region  is  not  deeply  covered 
with  muscles,  by  pressing  on  one  side  of  the  supposed  break 
and  observing  that  a  part  of,  and  not  the  entire,  rib  moves. 
Cellular  emphysema  without  a  surface-wound  is  proof  of  rib- 
fracture.  Bloody  expectoration  suggests  lung  injury;  bloody 


DISEASES  AND    INJURIES   OF  BONES  AND  JOINTS.    35  I 

expectoration  and  emphysema  prove  injury  of  the  lung.  A 
simple,  uncomplicated  case  in  a  young  person  gives  a  good 
prognosis. 

The  complications  are — additional  injur>',  making  the  fract- 
ure externally  or  internally  compound ;  laceration  of  pleura, 
pericardium,  heart,  lung,  diaphragm,  liver,  spleen,  or  colon ; 
rupture  of  an  intercostal  artery ;  hemothorax ;  cellular  em- 
physema ;  pulmonary  emphysema  ;  pneumothorax  and  pyo- 
thorax  ;  traumatic  pleurisy  ;  pneumonia  ;  bronchitis  ;  con- 
gestion or  edema  of  the  lungs. 

Treatment. — In  an  uncomplicated  case  the  patient  is  not 
put  to  bed,  as  breathing  is  easier  when  erect  than  when 
recumbent.  Angular  displacement  outward  is  corrected  by 
direct  pressure.  Displacement  inward  is  soon  corrected,  as 
a  rule,  by  the  expansion  of  ordinary  respiratory  action ;  but 
if  it  is  not  thus  corrected,  etherize,  the  deep  breathing  of  the 
anesthetic  state  almost  always  succeeding.  If  ether  fails  and 
dangerous  symptoms  come  on,  incise  under  strict  antiseptic 
guardianship,  elevate,  and  drain,  or  sometimes  resect  the  rib. 

After  correcting  any  existing  deformity  immobilize  the 
injured  side.  Direct  the  patient  to  raise  his  arms  above  his 
head,  to  empty  his  chest  by  a  forced  expiration,  and  to  keep 
it  empty  until  a  piece  of  rubber  plaster  (two  inches  wide)  is 
forcibly  applied  seven  or  eight  inches  below  the  fracture  and 
reaching  from  the  spine  to  the  sternum.  The  patient  is  now 
allowed  to  take  a  breath  and  is  directed  to  empty  the  chest 
again,  another  piece  of  plaster  being  applied,  covering  the 
upper  two-thirds  of  the  width  of  the  previous  strip.  This 
process  is  continued  until  the  side  is  strapped  well  above  and 
well  below  the  fracture  (PI.  5,  Fig.  13).  Over  the  plaster 
light  turns  of  an  inelastic  spiral  bandage  are  carried,  or  pref- 
erably a  figure-of-8  bandage  of  the  chest,  the  turns  crossing 
over  the  seat  of  injury.  About  once  a  week  the  plaster  is 
removed  and  fresh  pieces  applied  after  rubbing  off  the  chest 
with  soap  liniment,  drying,  and  anointing  excoriations  with 
an  ointment  of  oxid  of  zinc.  The  dressing  is  worn  for  three 
or  four  weeks.  The  patient  avoids  cold,  damp,  and  draughts. 
The  diet  is  to  be  nutritious  but  non-stimulating,  and  any 
cough  is  at  once  treated  by  opiates  and  expectorants.  A 
person  with  this  injury  who  has  reached  the  age  of  sixty 
must  take  stimulant  expectorants  (ammonii  carb.,  gr.  x,  in 
infus.  senegae,  oSs,  t.  i.  d.)  or  employ  a  steam-tent  several  times 
a  day.  The  old  method  of  treatment,  in  which  the  chest  was 
included  in  a  forcibly  applied  broad  rib-roller,  is  not  to  be 
used  except  as   a  temporary  expedient ;   it  compresses  the 


352  MODERN  SURGERY. 

entire  chest,  causes  pain  and  dyspnea,  and  tends  to  loosen 
and  slip. 

Fracture  of  the  ribs  complicated  with  visceral  injury  is 
highly  dangerous,  and  requires  confinement  to  bed.  The 
treatment  is  that  of  the  visceral  injury.  If  there  be  bloody 
expectoration,  apply  adhesive  strips  as  above  indicated,  put 
the  patient  to  bed  reclining  on  a  bed-rest,  keep  him  quiet, 
subdue  the  circulation,  and  employ  opium,  diaphoretics,  and 
expectorants  (a  good  mixture  consists  of  squill,  ipecac,  am- 
monium acetate,  and  chloroform  ;  opium  is  given  separately). 
Inflammations  of  the  lung  or  the  pleura,  fortunately,  are  apt 
to  be  localized,  and  are  treated  as  are  ordinary  inflammations 
of  these  parts.  If  signs  of  visceral  injury  are  severe  from  the 
start  or  become  worse  under  medical  treatment,  incise,  re- 
sect a  rib,  arrest  hemorrhage,  and  drain  the  pleura.  In  lacer- 
ation of  an  intercostal  artery  incise  and  try  to  ligate ;  if  un- 
able to  ligate,  resect  a  rib  and  apply  a  ligature.  If  the  signs 
point  to  internal  bleeding,  resect  a  rib,  search  for  the  bleed- 
ing point,  and  ligate.  Emphysema  usually  soon  disappears; 
but  if  it  does  not,  open  the  cellular  tissue,  dress  antiseptically, 
and  employ  pressure.  When  there  arises  a  sudden  attack 
of  dyspnea,  which  is  prone  to  happen  in  these  cases,  and  in 
which  there  are  a  blue  face  and  a  laboring  pulse  and  suffoca- 
tion seems  imminent,  bleed  the  patient  almost  to  syncope. 

Fracture  of  the  costal  cartilages  is  not  a  common  occur- 
rence, even  in  the  aged.  Such  fractures  occur  either  through 
the  cartilages  or  through  their  points  of  junction  with  the  ribs. 
These  injuries  generally  arise  from  direct  violence,  the  carti- 
lage of  the  eighth  rib  being  most  prone  to  suffer.  Indirect 
force  (such  as  a  blow  upon  the  shoulder)  is  occasionally  the 
cause,  but  when  it  is  the  cause  some  other  injury  is  apt  to  be 
noted.     Muscular  action  is  a  possible  cause. 

Symptoms. — Displacement  is  often  absent;  but  if  present,  it 
is  forward  or  backward  of  either  fragment,  and  is  due  chiefly 
to  the  force  of  the  injury,  but  partly,  it  may  be,  to  muscular 
action.  When  displacement  is  absent  crepitus  will  not  often 
be  found ;  in  fact,  crepitus  is  usually  absent  in  these  injuries. 
Localized  pain,  swelling,  and  ecchymosis  are  noted.  Preter- 
natural mobility  may  or  may  not  be  detected.  Union  by 
bone  is  to  be  expected. 

Treatment. — If  displacement  exists,  try  to  reduce  it.  If 
the  fragment  is  displaced  backward,  reduce  by  deep  inspira- 
tions ;  if  the  fragment  is  displaced  forward,  reduce  by  pull- 
ing back  the  shoulders.  In  this  attempt  failure  is  the  rule, 
and  the  surgeon  should  then  adopt  Malgaigne's  expedient 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    353 

of  applying  a  truss  over  the  projection  for  a  day  or  two. 
Dress  and  treat  the  case  as  if  a  rib  were  broken,  removing 
the  dressings  in  four  weeks. 

Fracture  of  the  Sternum. — The  sternum  may  be  broken, 
along  with  the  ribs  and  spine,  from  great  violence.  Fract- 
ures of  the  sternum  alone  are  infrequent,  because  the  bone 
rests  on  a  spring-bed  of  ribs.  Fractures  of  the  sternum  may 
be  simple  or  compound,  complete  or  incomplete,  single  or 
multiple.  The  most  usual  injury  is  a  simple  transverse  fract- 
ure at  or  near  the  gladiomanubrial  junction,  at  which  point 
dislocation  may  also  occur.  Both  fracture  and  separation 
of  the  ensiform  cartilage  are  very  rare.  The  sternum  may 
be  broken  along  with  the  ribs  or  clavicle. 

Cajises. — The  causes  of  fracture  of  the  sternum  are — 
direct  force,  as  by  falls  of  embankments  or  of  walls,  by  car- 
crushes,  or  by  the  passing  of  a  cart-wheel  over  the  body ; 
indirect  force,  as  by  falls  upon  the  head,  thus  driving  the 
chin  against  the  chest ;  by  falls  upon  the  feet,  the  buttocks, 
or  the  shoulder  ;  by  forced  flexion  or  extension  of  the  body 
over  an  edge  or  angle  (as  may  occur  during  labor-pains). 

Syjnptojiis. — In  fracture  of  the  sternum  displacement  is  not 
always  present,  but  when  it  does  occur  the  lower  fragment 
is  apt  to  go  forward ;  displacement  may,  however,  be  trans- 
verse or  angular,  or  there  may  be  overriding.  The  posterior 
periosteum,  which  rarely  tears,  limits  displacement,  but  some 
deformity  can,  as  a  rule,  be  detected.  The  history  of  the 
nature  of  the  accident  has  a  valuable  bearing  upon  the  ques- 
tion of  diagnosis.  The  position  assumed  by  the  patient  is 
with  the  head  and  body  bent  forward,  as  attempts  to  straighten 
up  cause  much  suffering.  There  is  fixed  and  localized  pain, 
increased  by  deep  respiratory  action,  by  body-movements,  or 
by  cough.  Crepitus  is  sought  for  by  auscultation  and  by 
placing  the  hand  over  the  injury  and  directing  the  patient  to 
make  quick  respirations.  Mobility  may  become  manifest  on 
external  pressure,  during  respiration,  or  while  attempts  are 
being  made  to  bring  the  body  erect.  Respiration  in  these 
cases  is  usually  much  interfered  with.  It  is  not  important  to 
separate  diastasis  from  fracture. 

Complications. — Other  fractures  generally  complicate  fract- 
ure of  the  sternum,  and  laceration  of  the  pleura  or  peri- 
cardium and  hemorrhage  into  the  anterior  mediastinum  may 
exist.  Abscess  of  the  mediastinum  and  necrosis  of  the  ster- 
num may  appear  as  late  consequences.  The  prognosis  is 
good  in  uncomplicated  cases. 

Treatment. — The  deformity  attending  fracture  of  the  ster- 

23 


354  MODERN  SURGERY. 

num  is  to  be  corrected,  if  possible,  by  external  pressure.  If 
overriding  is  found,  effect  reduction  by  bending  the  body 
back  over  a  firm  pillow  and  ordering  deep  respiration ;  if 
this  method  fails,  give  ether  and  then  bend  the  patient  back. 
The  deformity,  if  reduced,  tends  to  recur,  but  the  bones  unite 
well  in  deformity  and  no  great  harm  results.  The  fragments 
need  not  be  cut  down  on  or  hooked  up  unless  there  be  inter- 
nal injury.  After  reducing  the  deformity,  cover  the  front  of 
the  chest  with  adhesive  strips  extending  laterally  from  one 
axillary  line  to  the  other,  and  vertically  from  well  above  the 
fracture  down  to  the  ensiform  cartilage.  Place  over  this 
covering  an  anterior  figure-of-8  of  the  chest.  In  some  cases, 
where  deformity  recurs  after  reduction,  a  circular  bandage  of 
the  chest  is  applied  and  the  shoulders  are  pulled  strongly 
back  with  a  posterior  figure-of-8  bandage.  The  plaster  is  to 
be  renewed  once  a  week. 

Some  surgeons  treat  these  cases  by  means  of  a  large 
compress  held  by  adhesive  plaster  and  a  broad  tight  roller. 
The  patient,  however  dressed,  is  put  to  bed  and  reposes  erect 
or  semi-erect  on  a  bed-rest.  This  position  favors  easy  respi- 
ration and  antagonizes  the  tendency  to  displacement.  The 
diet  should  be  light,  nutritious,  and  non-stimulating.  The 
patient  is  convalescent  in  four  weeks,  and  the  plaster  is  per- 
manently taken  off  in  five  weeks.  When  the  ensiform  carti- 
lage is  so  bent  in  as  to  cause  intense  pain  or  injure  the 
stomach,  it  should  be  incised  and  resected.  Edema  of  the 
skin  and  fever,  if  they  appear,  indicate  pus,  in  which  case  an 
incision  is  made  at  the  edge  of  the  sternum  and  the  pus- 
cavity  is  irrigated,  drained,  and  dressed  antiseptically. 

Fractures  of  the  Pelvis. — In  some  of  the  indicated  fract- 
ures serious  injury  of  the  pelvic  contents  is  apt  to  be  found. 

Fractures  of  the  False  Pelvis. — Fractures  of  this  region 
are  seldom  dangerous  unless  comminuted.  There  may  be 
fracture  of  the  iliac  crest  or  of  the  anterior  superior  spine, 
or  the  line  of  fracture  may  traverse  the  entire  length  of  the 
flanged-out  ilium  or  the  bone  may  be  comminuted  with  the 
association  of  grave  visceral  damage.  The  anterior  superior 
and  posterior  superior  spines  may  be  broken  off. 

Causes. — The  cause  of  fracture  of  the  false  pelvis  is  gen- 
erally violent  direct  force,  as  the  passage  of  a  wagon-wheel, 
the  fall  of  a  wall,  the  kick  of  a  mule,  or  the  force  of  car- 
crushes.  Violent  contraction  of  the  rectus  muscle  may  tear 
off  the  anterior  inferior  spine  of  the  ilium. 

Symptoms. — In  fracture  of  the  false  pelvis  the  history  of 
violent  force  is  noted.     The  patient  leans  toward  the  injured 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    355 

side.  Pain  exists,  which  is  aggravated  by  movements  (par- 
ticularly by  bending  forward),  by  coughing,  or  by  straining 
to  empty  the  bowels  or  the  bladder.  Ecchymosis  and  swell- 
ing are  manifest.  Crepitus  and  preternatural  mobility  are 
detected  by  moving  the  crest.  Deformity  is  very  rarely  pres- 
ent. Cases  uncomplicated  by  visceral  injury  make  good 
recoveries. 

Coniplications. — The  fracture  may  be,  but  rarely  is,  com- 
pound, as  the  parts  are  well  protected  with  muscles.  The 
colon  may  be  injured  when  comminution  has  taken  place. 

Treatment. — In  treating  fracture  of  the  false  pelvis  put 
the  patient  on  a  fracture-bed,  raise  the  shoulders,  and  put  a 
binder  about  the  pelvis,  or  encase  the  pelvis  with  broad  pieces 
of  rubber  plaster,  or  employ  the  belt  or  girdle.  Place  the 
knees  over  two  pillows  so  as  to  semiflex  the  legs  and  thighs, 
and  tie  the  knees  together.  To  restrain  thigh-movements  it 
may  be  necessary  to  encase  a  restless  patient  with  splints  or 
bind  him  to  sand-bags.  If  the  binder  displaces  the  fragments 
or  causes  pain,  abandon  it  and  trust  to  position.  The  dress- 
ings can  be  removed  in  six  weeks,  and  the  patient  is  allowed 
to  get  up  in  eight  weeks.  In  compound  fractures  of  the  false 
pelvis  asepticize,  drain  and  dress,  put  on  a  binder,  and  direct 
the  same  position  to  be  maintained  as  for  simple  fractures. 

Fractures  of  the  True  Pelvis. — The  most  usual  seat  of 
these  fractures  is  through  the  obturator  foramen,  the  ascend- 
ing ischial  and  horizontal  pubic  rami  being  broken.  A  fract- 
ure may  occur  near  the  symphysis  pubis,  the  symphysis 
may  be  separated,  a  break  may  run  near  to  or  into  the  sacro- 
iliac joint,  the  same  fracture  may  occur  on  each  side  of  the 
body  of  the  pubis,  and  there  may  be  multiple  fractures. 
Fractures  of  the  acetabulum  and  of  the  tuberosity  of  the  is- 
chium may  occur.  Before  the  seventeenth  year  the  innomi- 
nate bone  may  be  broken  into  its  three  anatomical  segments. 
These  injuries  are  highly  dangerous  because  of  the  damage 
which  is  apt  to  be  inflicted  on  the  pelvic  contents.  There 
may  be  rupture  of  the  bladder  or  membranous  urethra 
and  injury  of  the  vagina,  the  rectum,  the  uterus,  or  the 
small  gut.  The  cause  of  pelvic  fracture  is  violent  force, 
direct  or  indirect.  Front  force  tends  to  produce  direct,  and 
side  force  indirect,  fracture. 

Symptoms. — In  pelvic  fracture  there  is  a  history  of  violent 
force.  There  are  great  shock,  ecchymosis  which  is  possibly 
linear,  swelling,  and  intense  pain  increased  by  attempts  at 
motion,  coughing,  and  straining.  There  is  also  inability  to 
sit  or  to  stand.     Mobility  becomes  obvious  on  grasping  an 


356  MODERN  SURGERY. 

ilium  in  each  hand  and  moving  the  hands.  Crepitus  may  be 
noticed  by  this  manoeuver  or  by  moving  an  ilium  with  one 
hand,  a  finger  of  the  other  hand  being  inserted  in  the  rectum 
or  in  the  vagina.  In  making  movements  for  diagnostic  pur- 
poses be  very  gentle,  as  rough  manipulation  permits  of 
injury  by  sharp  fragments.  There  may  be  doubt  as  to 
whether  crepitus  is  to  be  referred  to  pelvic  fracture  or  to 
fracture  of  the  neck  of  the  femur;  in  this  case  follow  the 
rule  of  John  Wood :  "  The  surgeon  grasps  the  femur  with 
one  hand  and  places  the  other  firmly  upon  the  anterior 
superior  iliac  spine  or  crest  or  upon  the  pubes ;  then,  on 
moving  the  femur  and  abducting  it  freely,  if  a  crepitus  be 
detected,  it  will  be  felt  the  more  distinctly  by  that  hand 
which  rests  on  or  grasps  the  fractured  bone." 

Injury  of  the  bladder  or  urethra  is  made  manifest  by 
retention  of  urine,  extravasation  of  urine,  hematuria,  etc. 
In  some  cases  the  urine  is  extravasated  into  the  prevesical 
space.  Bleeding  from  the  vagina  or  the  rectum  points  to  a 
laceration  of  the  part  by  a  fragment.  Intestinal  injury 
induces  septic  peritonitis.  Fractures  of  the  brim  of  the 
acetabulum  permit  dorsal  dislocation  of  the  femur  to  occur, 
which  dislocation  will  not  remain  reduced.  The  acetabulum 
may  be  broken  by  falls  upon  the  feet.  Fracture  of  the  brim 
of  the  acetabulum  causes  shortening,  which  at  once  recurs 
when  extension  is  abandoned — inversion  and  adduction, 
although  the  power  of  eversion  and  abduction  is  preserved 
(Stokes).  There  is  crepitus,  and  the  head  of  the  bone  goes 
with  the  fragment  upward  and  backward  (Stokes).  If  the 
head  of  the  femur  be  driven  through  the  acetabulum  into 
the  pelvis,  the  injury  is  very  grave ;  there  are  then  found 
shortening,  adduction,  and  semiflexion  of  the  thigh,  absence 
of  the  prominence  of  the  great  trochanter,  and  more  capacity 
for  movement  than  is  noted  in  dislocation.  Fracture  of  the 
ischium  rarely  occurs  alone. 

Treatment. — In  treating  pelvic  fractures  endeavor  to  re- 
store the  parts  to  a  normal  position,  employing  external 
manipulation  and  inserting  a  finger  in  the  rectum  or  in  the 
vagina.  If  reduction  is  difficult,  give  ether.  Use  a  catheter 
before  dressing,  to  detect  any  bladder-injury.  Treat  as  in 
fractures  of  the  false  pelvis,  attending  carefully  to  visceral 
injuries.  If  urinary  extravasation  occurs,  effect  a  perineal 
section.  If  peritonitis  develops,  perform  a  laparotomy.  All 
visceral  injuries  are  treated  by  general  rules.  Remove  the 
dressings  in  six  weeks,  and  allow  the  patient  to  be  about 
in  twelve  weeks.     In  fracture  of  the  acetabulum,  if  the  limb 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    357 

be  shortened,  give  ether  and  reduce.  Treat  these  fractures 
in  the  same  way  as  intracapsular  fractures  of  the  femur 
(p.  386).  Fractures  of  the  ischium  are  best  treated  by 
position,  the  pad,  and  adhesive  plaster. 

Fracture  of  the  Sacrum. — This  injury  may  arise  from 
direct  force,  such  as  a  kick,  but  it  is  very  rare.  The  sacral 
plexus  is  usually  injured,  and  if  it  is  there  is  paralysis  in  the 
territory  of  its  branches. 

Symptoms. — The  symptoms  in  fracture  of  the  sacrum  are 
pain,  frequently  incontinence  of  feces  and  retention  of  urine, 
irregularity  of  the  sacral  spines,  ecchymosis,  and  crepitus. 
Crepitus  may  be  sought  for  with  one  hand  externally  and  a 
finger  of  the  other  hand  in  the  rectum.  The  lower  fragment 
goes  forward  and  may  obstruct  or  may  tear  the  rectum. 
Paralysis  may  be  found  in  the  area  of  distribution  of  the 
sacral  plexus. 

Treatment. — In  treating  fracture  of  the  sacrum  press  the 
fragments  into  place  with  a  hand  externally  and  a  finger  in 
the  rectum.  Do  not  plug  the  rectum.  Put  a  pad  over  the 
upper  fragment,  hold  it  with  plaster  or  a  binder,  place  the 
patient  recumbent  on  a  fracture-bed,  and  insert  a  large 
cushion  underneath  the  pad.  Some  surgeons  give  opium 
to  induce  constipation,  and  allow  a  fecal  support  to  accu- 
mulate in  the  rectum.  Use  a  clean  catheter  regularly,  and 
guard  against  bed-sores.  Union  occurs  in  about  four  weeks, 
when  the  dressing  can  be  removed.  The  patient  can  get 
about  again  in  six  weeks.  If  urinary  retention  persists  or 
if  intractable  bed-sores  form  after  eight  or  ten  weeks,  cut 
down  on  the  seat  of  injury  and  elevate  or  remove  the  portion 
of  bone  causing  pressure. 

Fractures  of  the  Coccyx. — The  coccyx  may  be  broken 
or  be  separated  from  the  sacrum  by  a  fall,  a  blow,  a  kick, 
or  the  straining  of  parturition.  Its  mobility  is  so  great, 
however,  that  it  does  not  often  break. 

Symptoms. — The  chief  symptom  of  fracture  of  the  coccyx 
is  pain,  which  is  much  aggravated  by  sitting,  walking,  or 
straining  at  stool.  If  the  index  finger  is  inserted  in  the 
rectum,  the  displaced  bone  is  felt ;  if  the  thumb  of  the  same 
hand  is  also  placed  externally,  a  rocking  motion  will  develop 
crepitus  and  preternatural  mobility. 

Treatment. — In  treating  fracture  of  the  coccyx  reduce  by 
external  pressure  and  by  the  manipulations  of  a  finger  in 
the  rectum.  Put  the  patient  to  bed  and  obstruct  the  bowels 
by  opium  for  a  number  of  days.  In  four  weeks  the  fracture 
should  be  united.     If  union  does  not  take  place,  defecation 


358  MODERN  SURGERY. 

and  all  movements  of  the  coccyx  will  cause  excruciating 
pain  by  pressure  on  the  last  sacral  nerve.  This  condition, 
known  as  "  coccygodynia,"  demands  a  subcutaneous  division 
of  the  nerve  or  of  the  muscles  which  move  the  coccyx,  or  a 
resection  of  the  bone. 

Fractures  of  the  Vertebra.     (See  p.  592.) 

Fractures  of  the  Skull.     (See  p.  549.) 

Fracture  of  the  Clavicle. — The  clavicle  is  more  often 
fractured  than  any  other  bone.  This  fracture  may  occur  at 
any  age,  but  is  notably  common  before  the  sixth  year  (Hulke 
says  one-half  of  the  recorded  cases).  It  may  be  simple,  mul- 
tiple, comminuted,  oblique,  transverse,  complete,  incomplete, 
or,  very  rarely,  compound.  Both  clavicles  may  be  broken. 
Fractures  are  most  apt  to  occur  just  external  to  the  middle, 
at  the  point  where  the  inner  or  large  curve  meets  the  outer 
or  small  curve,  at  which  junction  the  bone  is  at  its  smallest 
diameter.  Fractures  of  the  acromial  end  are  more  frequent 
than  fractures  of  the  sternal  end,  and  less  frequent  than  fract- 
ures of  the  shaft.  The  causes  of  clavicle-fractures  are  direct 
violence,  indirect  violence,  and,  very  rarely,  the  contractions 
of  "  the  deltoid  and  clavicular  fibers  of  the  great  pectoral " 
(Treves,  from  Polaillon). 

Fractures  of  the  shaft  are  usually  due  to  indirect  vio- 
lence, as  falls  upon  the  shoulder  or  upon  the  outstretched 
hand.  In  the  latter,  which  is  the  usual  mode  of  origin,  the 
concussion  of  the  fall  travels  up  and  the  body-weight  travels 
down,  and  these  two  forces  compress  the  bone,  which  snaps 
at  its  weakest  point.  Fractures  from  indirect  force  are 
obhque,  and  in  children  are  of  the  green-stick  form.  Fract- 
ures from  direct  force  are  usually  transverse,  and  are  occa- 
sionally comminuted.  Fractures  from  muscular  action  have 
been  recorded  (Rubini  the  tenor,  recorded  by  Melay). 

Syviptojns. — In  fractures  of  the  shaft  the  attitude  of  the 
patient  is  peculiar.  He  supports  the  elbow  or  wrist  of  the 
injured  side  with  the  hand  of  the  sound  side,  and  also  pulls 
the  extremity  against  the  chest ;  the  head  is  turned  down 
toward  the  shoulder  of  the  damaged  side,  as  if  trying  to 
listen  to  something  in  the  joint,  thus  relaxing  the  pull  of 
the  sterno-cleido-mastoid  muscle  upon  the  inner  fragment. 
The  shoulder  is  nearer  the  sternum,  on  a  lower  level,  and 
farther  front  than  that  of  the  sound  side.  Loss  of  func- 
tion is  shown  by  inability  to  abduct  the  arm.  Considerable 
pain  exists,  which  is  increased  by  motion,  by  pressure,  and 
by  hanging  down  the  extremity  without  support. 

The  deformity  above  noted  is   described  by  stating  that 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    359 

the  shoulder  goes  downward,  inward,  and  forward  (d.  i.  f.). 
The  doivnzvard  deformity  is  chiefly  due  to  the  weight  of  the 
arm,  which  pulls  down  the  unsupported  outer  fragment,  and 
is  contributed  to  by  the  action  of  the  pectoralis  minor 
muscle.  The  imvard  deformity  is  chiefly  due  to  the  con- 
traction of  the  pectoralis  minor  and  subclavius  muscles 
assisted  by  the  action  of  the  pectoralis  major.  The  forward 
deformity  is  due  to  rotation  of  the  outer  fragment,  which  is 
brought  about  by  the  serratus  magnus  muscle  carrying  the 
scapula  forward.  In  this  deformity  the  inner  end  of  the 
outer  fragment  is  below  and  behind  the  outer  end  of  the 
inner  fragment,  which  overrides  it.  The  inner  fragment, 
though  pulled  on  by  the  sternomastoid  and  relatively  higher 
than  the  outer  fragment,  is  really  but  little,  if  at  all,  elevated, 
marked  elevation  being  prevented  by  the  attachment  of  the 
rhomboid  ligament.  After  noting  the  deformity,  detect  with 
the  finger  the  irregularity  of  bony  contour.  Examine  for 
preternatural  mobility  and  crepitus  by  raising  and  throwing 
back  the  shoulder.  In  looking  for  these  signs  in  children  it 
is  to  be  remembered  that  the  fracture  is  probably  incomplete. 
The  prognosis  is  good,  the  bone  uniting,  but  always  with 
some  shortening  and  inequality. 

Complications. — Fractures  of  the  shaft  are  rarely  com- 
pound, because  the  sharp  end  of  the  outer  fragment  goes 
back  and  because  of  the  free  play  the  skin  makes  over  the 
bone  (Pickering  Pick).  Both  clavicles  may  be  broken.  In 
fractures  from  direct  force  deeper  structures  may  be  injured 
by  fragments.  Thus,  injury  of  the  brachial  plexus  will 
induce   paralysis.     Ribs  may  be  broken  at  the  same  time. 

Treatment. — In  treating  fractures  of  the  shaft  reduce  the 
fracture  as  soon  as  possible  by  throwing  the  shoulder 
upward,  outward,  and  backward.  If  the  patient  is  a  girl, 
it  is  desirable  to  minimize  the  deformity.  Place  her  upon 
her  back  on  a  hard  bed,  with  a  small  pillow  under  her  head, 
a  firm  and  narrow  cushion  between  the  shoulders,  a  bag 
of  shot  resting  over  the  seat  of  fracture,  and  the  forearm 
lying  on  the  front  of  the  chest,  the  arm  being  held  to 
the  side  by  a  sand-bag.  In  three  weeks  there  will  be  union, 
practically  without  deformity.  In  a  child  with  an  incomplete 
fracture  a  handkerchief  sling  for  the  forearm,  worn  three 
weeks,  is  all  that  is  needed.  In  complete  fracture  the 
Velpeau  bandage  is  efficient  (Fig.  273).  Before  applying 
it,  place  lint  around  the  chest  and  cotton  over  the  elbow. 
Change  the  bandage  every  day  for  the  first  week,  and  after 
that  period  every  third  day.     Each  time  it  is  changed  rub 


360 


MODERN  SURGERY. 


the  skin  with  alcohol,  ethereal  soap,  or  soap  liniment,  then 
dry  it  and  examine  for  excoriations,  which,  if  any  are  found, 
are  anointed  with  zinc  ointment  before  the  dressing  is  reap- 
plied. The  dressing  is  permanently  removed  at  the  end  of 
four  weeks,  the  arm  being  worn  in  a  sling  for  another  week. 
The  classical  apparatus  of  Desault  is  now  rarely  used  (Fig. 

276).  The  posterior  fig- 
ure-of-8  bandage  associ- 
ated with  the  second  roller 
of  Desault,  some  turns 
being  made  from  the  elbow 
of  the  injured  side  to  the 
shoulder  of  the  well  side, 
can  be  used  in  cases  in 
which  the  forward  deform- 
ity is  apt  to  return.  The 
apparatus  of  Fox,  which 
is  very  useful,  consists  of  a 
pad  for  the  axilla,  a  sling 
for  the  forearm,  and  a  ring 
for  the  opposite  shoulder, 
to  which  ring  are  tied  the 
tapes  from  both  the  pad 
and  the  sling  (Fig.  75). 
The  dressinsf  of  Moore  of  Rochester  is  valuable  in  an 
emergency.  It  consists  of  a  piece  of  cotton  cloth,  two  yards 
long,  and  folded  Hke  a  cra- 
vat until  it  is  eight  inches 
in  width  at  the  middle.  The 
center  of  the  bandage  rests 
upon  the  elbow,  the  poste- 
rior tail  is  carried  across 
the  front  of  the  shoulder 
of  the  injured  side.  The 
forearm  is  at  an  acute  angle 
with  the  arm,  and  the  other 
end  of  the  bandage  is  car- 
ried across  the  forearm, 
across  the  back  over  the 
opposite  shoulder,  and 
around  the  axilla,  where 
the  extremities  are  stitched  together.  The  forearm  is  sus- 
pended in  a  bandage  sling  (S.  D.  Gross).  The  four-tailed 
bandage  is  preferred  by  Pick.  Sayre's  dressing  has  many 
advocates  (Fig.  76).     For  this  there  are  required  two  pieces 


Fig.  75. — Fox's  apparatus  for  fractured  clavicle. 


Fig.  76. — Sayre's  adhesive-plaster  dressing 
for  fracture  of  the  clavicle  (Stimson)  :  A,  first 
piece;  .5,  second  piece. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    36 1 

of  rubber  plaster,  each  piece  being  three  inches  wide  and 
sufficiently  long  to  go  around  the  chest  one  and  a  half  times. 
The  end  of  one  piece  encircles  the  arm  of  the  injured  side  just 
below  the  arm-pit ;  the  plaster  strip  is  pulled  across  the  back 
to  the  other  side,  to  the  front  of  the  chest,  and  returns  again 
to  the  middle  of  the  back.  This  procedure  pulls  the  elbow 
back  and  throws  the  shoulder  out.  The  hand  of  the  injured 
side  is  placed  on  the  breast  of  the  opposite  side,  cotton 
being  interposed,  and  the  second  strip  of  plaster  runs  from 
the  elbow  of  the  injured  side  and  the  opposite  shoulder, 
front,  around,  and  back,  pressing  the  elbow  forward,  upward, 
and  inward.  If  the  fragments  cannot  be  coaptated,  incise, 
clear  away  the  muscle  from  between  them,  saw  the  ends,  bore 
each  end  and  hold  them  in  contact  by  means  of  kangaroo- 
tendon  or  silver  wire.  The  same  procedure  should  be  pur- 
sued when  a  fracture  is  compound  or  threatens  to  become  so. 

In  any  fracture,  if  signs  indicate  pressure  upon  vessels  or 
nerves,  incise,  lift  fragments  into  place  and  wire  them.  If  the 
patient  refuses  this  operation,  put  him  to  bed  and  abduct  the 
arm.  If  a  vessel  is  injured,  operation  is  imperatively  neces- 
sary. After  removing  the  dressings,  if  the  shoulder  is  found 
to  be  stiff,  make  passive  movements  daily  ;  if  these  fail,  break 
up  the  adhesions  after  giving  ether  or  nitrous  oxid. 

Fracture  of  the  acromial  end  of  the  clavicle  is  due  to 
direct  force.  If  the  fracture  is  between  the  two  coraco- 
clavicular  ligaments,  deformity  is  very  slight,  crepitus  is 
elicited  by  manipulating  with  the  fingers,  and  pain  exists,  but 
loss  of  function  is  not  markedly  manifest  unless  it  is  due  to 
pain.  These  fractures  are  treated  by  binding  the  arm  to  the 
side  with  the  second  roller  of  Desault,  interposing  cotton 
between  the  arm  and  the  side,  and  hanging  the  hand  in  a 
sling.  In  fractures  external  to  the  ligaments  crepitus  is 
manifest  on  moving  the  shoulder,  the  outline  of  the  bone  is 
irregular,  severe  pain  exists  on  movement,  and  deformity  is 
pronounced.  The  deformity  is  due  to  the  serratus  magnus 
muscle  rotating  the  scapula  forward,  the  inner  end  of  the 
outer  fragment  of  the  clavicle  often  coming  in  contact  with  the 
anterior  surface  of  the  outer  portion  of  the  inner  fragment. 
This  fracture  is  reduced  by  pulling  both  of  the  shoulders 
strongly  backward,  and  it  is  kept  reduced  by  a  posterior  fig- 
ure-of-8  bandage.  In  fracture  external  to  the  ligaments  the 
displacement  frequently  cannot  be  corrected  by  position  and 
manipulation.  Such  cases  demand  incision  and  wiring.  In 
either  fracture  the  dressings  are  worn  for  four  weeks. 

In  children,  if  it  is  found  difficult  to  immobilize  the  parts, 


362  MODERN  SURGERY. 

the  most  satisfactory  result  is  obtained  by  the  apphcation  of 
the  Velpeau  bandage,  which  is  to  be  overlaid  by  a  plaster 
bandage. 

Fracture  of  the  sternal  end  of  the  clavicle  is  very  rare. 
It  is  caused  by  either  direct  or  indirect  force.  There  are 
found  crepitus,  projection  at  the  seat  of  fracture,  rigidity  of 
the  sternomastoid  muscle,  and  shortening  of  the  clavicle. 
The  inner  end  of  the  outer  fragment  always  goes  forward, 
and  often  also  downward  and  inward.  Reduce  these  fract- 
ures by  pulling  the  shoulders  back,  and  treat  them  by 
means  of  the  posterior  figure-of-8  bandage  worn  for  four 
weeks.     Wiring  may  be  necessary. 

Fracture  of  the  Scapula. — This  bone  is  not  often  broken, 
as  it  rests  upon  thick  muscles  and  elastic  ribs  ;  it  is  freely 
movable,  and  it  has  attached  to  it  a  bone  which,  easily  breaks. 
Fractures  of  the  body  of  the  bone  are  due  to  direct  violence. 
The  symptoms  are  pain  (which  becomes  agonizing  on 
attempting  to  rotate  the  shoulder-blade),  ecchymosis,  and 
swelling.  Crepitus  is  sought  for  by  placing  the  hand  over 
the  bone  and  making  movements  of  the  arm ;  also  by  hold- 
ing the  point  of  the  shoulder  and  lifting  up  the  lower  angle 
of  the  bone.  The  latter  plan  may  display  mobility.  The 
spine  of  the  scapula  is  uneven  only  when  it  itself  is  fractured. 
Examine  for  unevenness  of  the  vertebral  border.  In  fract- 
ures of  the  body  of  the  scapula  a  shoulder-cap  should  be 
applied,  a  gutta-percha  splint  must  be  moulded  over  the 
scapula,  the  arm  is  bound  to  the  side,  and  the  hand  is 
carried  in  a  .sHng.  The  apparatus  is  worn  for  four  weeks. 
Fractures  of  the  spine  of  the  scapula  are  treated  as  are  fract- 
ures of  the  body  of  the  bone,  and  for  the  same  time. 

Fractures  of  the  Neck. — Fracture  of  the  anatomical  neck 
has  not  been  proved  to  exist.  Fracture  of  the  surgical  neck 
is  evinced  by  flattening  of  the  shoulder,  prominence  of  the 
acromion,  and  a  lump  in  the  axilla  which  gives  crepitus  on 
pressure  upward  and  backward.  The  deformity  is  reduced 
with  ease,  but  it  at  once  recurs.  It  is  treated  by  placing  a 
pad  in  the  axilla,  a  shoulder-cap  on  the  shoulder,  applying 
the  second  roller  of  Desault,  and  supporting  the  forearm  and 
elbow  in  a  sling.  A  Velpeau  dressing  can  be  used,  associated 
with  a  folded  towel  in  the  axilla.  The  dressing  is  to  be  worn 
for  five  weeks. 

Fracture  of  the  glenoid  cavity,  which  is  not  very  unusual, 
may  occur  with  or  without  dislocation.  It  arises  from  direct 
force  applied  to  the  shoulder.  The  existence  of  this  fracture 
is  determined  by  excluding  fractures  of  other  bones  and  by 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    363 

detecting  crepitus  when  the  arm  is  at  right  angles  to  the 
body  and  the  humerus  is  pushed  against  the  glenoid  cavity, 
the  crepitus  not  being  found  when  the  arm  hangs  by  the  side. 

Tnatinciit  here  is  by  the  second  roller  of  Desault  and  a 
forearm  sling  for  four  weeks ;  by  careful  passive  movements 
limit  ankylosis,  but,  if  it  occurs,  it  will  have  to  be  broken  up 
while  the  patient  is  under  ether  or  nitrous  oxid. 

Fracture  of  the  acromion  is  often  met  with  as  the  result 
of  direct  violence.  Its  existence  is  indicated  by  pain,  by  in- 
ability to  abduct  the  arm,  by  flattening  of  the  shoulder,  by 
sudden  lowering  of  the  point  of  the  shoulder,  by  mobility, 
and  by  crepitus.  To  treat  a  case  of  this  kind,  put  a  large 
pad  in  the  axilla  with  the  base  down,  bind  the  arm  over  the 
pad  with  the  second  roller  of  Desault,  lifting  the  elbow  with 
turns  of  the  roller  carried  over  it  and  the  opposite  shoulder, 
thus  splinting  the  bone  in  place  by  the  head  of  the  humerus 
pushing  against  the  coraco-acromial  ligaments.  The  dress- 
ing is  to  be  worn  for  four  weeks. 

Fracture  of  the  coracoid,  which  rarely  happens  alone, 
may  arise  from  direct  force  or  from  muscular  action.  But 
little  displacement  is  found.  Crepitus  and  mobility  are  usu- 
ally detected.  Inability  to  shrug  the  shoulder  inward  was 
pointed  out  as  a  symptom  by  Byers.  These  cases  are  well 
treated  by  the  Velpeau  bandage,  which  is  to  be  worn  for  four 
weeks. 

Fractures  of  the  humerus  are  div^ided  into  (i)  fractures 
of  the  upper  extremity ;  (2)  fractures  of  the  shaft ;  and  (3) 
fractures  of  the  lower  extremity.  In  examining  any  fracture 
of  the  humerus,  feel  at  once  for  the  pulse,  so  as  to  ascertain 
if  the  artery  has  been  torn  ;  in  any  fracture  near  the  head  of 
the  humerus  be  certain  that  there  is  no  dislocation. 

I.  Fractures  of  the  upper  extremity  include  {a)  fractures 
of  the  anatomical  neck ;  (/?)  fractures  of  the  surgical  neck ; 
{c)  fractures  of  the  head,  oblique  and  longitudinal ;  and  {d) 
separation  of  the  upper  epiphysis. 

Fractures  of  the  Anatomical  Neck  of  the  Humerus. — 
The  anatomical  neck  is  the  constricted  circumference  of  the 
articular  surface,  and  fractures  of  it,  though  rare,  do  occur, 
especially  in  the  aged.  The  line  of  fracture  in  some  cases 
follows  the  insertion  of  the  capsule,  in  others  it  is  entirely 
within  the  capsule,  but  in  most  it  is  without  the  capsule 
above  and  within  the  capsule  below ;  hence  the  term  "  intra- 
capsular "  is  rarely  correct  as  a  designation.  The  cause  is 
direct  violence. 

Symptoms. — The  symptoms  in  fracture  of  the  anatomical 


364  '     MODERN  SURGERY. 

neck  are  pain,  swelling,  ecchymosis,  slight  irregularity  of  the 
shoulder  (which  irregularity  is  soon  hidden  by  tumefaction), 
and  inability  to  abduct  the  arm  voluntarily.  Deformity,  as 
a  rule,  is  slight  or  is  absent,  because  the  capsule  is  rarely  en- 
tirely torn  from  the  lower  fragment.  If  deformity  exists,  it  is 
due  to  the  muscles  inserted  on  the  bicipital  groove  and  to  the 
coracobrachialis,  which  pull  the  lower  fragment  inward  and 
forward.  Treves  says  that  a  tear  of  the  reflected  fibers  of  the 
capsule  leads  to  subsequent  necrosis,  because  this  joint  has 
no  ligamentum  teres.  In  some  cases  impaction  occurs,  the 
upper  fragment  impacting  in  the  lower.  In  this  condition 
there  is  very  sHght  shortening  and  shoulder-flattening,  no 
crepitus  unless  the  tuberosity  is  broken  off,  and,  as  Erichsen 
says,  the  head  of  the  bone,  while  it  can  be  felt  through  the 
axilla,  is  not  in  the  axis  of  the  limb. 

The  prognosis  of  this  fracture  is  good  for  bony  union  (Ham- 
ilton, Pick,  and  R.  W.  Smith),  but  a  stiff  joint  is  apt  to  result. 

Treatment. — Some  surgeons  treat  this  fracture  by  simply 
hanging  the  wrist  in  a  sling  and  suspending  a  bag  of  shot  from 
the  elbow  to  make  extension.  The  usual  plan  of  treatment  is 
as  follows :  flex  the  arm  to  a  right  angle  with  the  body,  and 
carry  up  from  the  base  of  the  fingers  to  above  the  elbow  the 
turns  of  a  spiral  reverse  bandage.  Interpose  lint  between  the 
arm  and  the  side,  and  place  a  folded  towel  or  a  small  pad  in  the 
axilla,  tying  the  tapes  over  the  opposite  shoulder.  Mould  a 
shoulder-cap  (PI.  5,  Fig.  8)  upon  the  outer  aspect  of  the  arm 
and  upon  the  shoulder.  This  cap,  which  is  made  of  paste- 
board or  of  felt,  should  reach  below  the  insertion  of  the  deltoid, 
cover  one-half  the  circumference  of  the  arm,  and  is  to  be 
padded  with  cotton.  The  arm  with  the  shoulder-cap  is  fixed 
to  the  side  by  the  second  roller  of  Desault,  and  the  hand  is 
hung  in  a  sling.  The  edges  of  the  bandage  had  best  be 
stitched.  This  apparatus  is  changed  daily  for  the  first  few 
days,  the  body  and  arm  being  rubbed  at  each  change  with 
alcohol,  soap  liniment,  or  ethereal  soap.  After  this  period  a 
change  every  third  or  fourth  day  is  often  enough.  Passive 
motion  is  started  at  the  end  of  four  weeks,  and  the  dressings 
are  removed  at  the  end  of  six  weeks.  In  impacted  fracture 
do  not  pull  apart  the  impaction,  but  apply  a  cap  to  the  shoul- 
der and  fix  the  arm  to  the  side  for  five  weeks.  No  pad  is 
used.     The  fracture  unites  with  deformity. 

Fractures  of  the  Surg-ical  Neck  of  the  Humerus. — The 
surgical  neck  is  the  constricted  portion  of  bone  between  the 
tuberosities  and  the  upper  line  of  the  insertion  of  the  muscles 
on  the  bicipital  groove.     Fractures  in  this  region  are  usually 


SPLINTS. 


Plate  5. 


I.  Fracture-box.  2.  Double  IncHned  Plane  Fracture-box.  3.  Jaw-cup  (unfolded).  4.  Jaw-cup 
(folded).  5.  Anterior  Angular  Splint.  6.  Internal  Angular  Splint.  7.  Bond  Splint.  8.  Shoulder-cap. 
9.  Dupuytren  Splint  in  Pott's  Fracture.  10.  Agnew  Splint  for  Fracture  of  the  Metacarpus.  11.  Agnevv 
Splint  for  Fracture  of  the  Patella.  12.  Agnew  Splint  applied.  13.  Strapping  the  Chest  in  Fractured 
Ribs.  14.  Extension  Apparatus  in  Fracture  of  the  Femur.  15,  16.  Adhesive  Strips  for  Extension 
Apparatus. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    365 


transverse,  but  they  may  be  oblique.  The  causes  arc — direct 
force  almost  always  ;  indirect  force  occasionally ;  and  mus- 
cular action  in  rare  instances. 

SytiiptoJiis. — The  symptoms  in  fracture  of  the  surgical  neck 
are — pain  running  into  the  fingers  from  pressure  upon  the 
brachial  plexus ;  crepitus  and  mobility  on  extension ;  and 
flattening,  which  differs  from  the  flattening  of  dislocation  in 
that  it  occurs  farther  below  the  acromion  and  that  this  pro- 
cess is  not  so  prominent.  Shortening  to  the  extent  of  an 
inch  is  noted.  The  head  of  the  bone  can  be  felt  in  the  gle- 
noid cavity,  but  it  does  not  move  on  rotating  the  arm.  The 
upper  end  of  the  lower  fragment  is  felt  and  moves  on  rotat- 
ing the  arm.  The  displacement  is  pronounced.  The  lower 
fragment  is  pulled  upward  by  the  deltoid,  biceps,  coraco- 
brachialis,  and  triceps  ;  inward  by  the  muscles  of  the  bicipital 
groove ;  and  forward  by  the  great  pectoral ;  thus,  the  upper 
end  of  the  lower  fragment  projects  into  the  axilla,  and  the 
elbow  lies  from  the  side  and  backward.  Pean  holds  that  the 
violence  sends  the  lower  fragment  forward.  The  upper  frag- 
ment is  abducted  and  rotated  outward,  which  position  is  due, 
it  is  generally  taught,  to  the  action  of  the  supraspinatus,  in- 
fraspinatus, and  teres  minor  muscles.  In  some  cases  dis- 
placement is  forward,  and  in  other  cases  it  is  not  obvious. 
The  lower  fragment  may  impact  into  the  upper,  in  which  case 
the  symptoms  are  obscure  and  the  diagnosis  is  made  by  ex- 
clusion. If  the  impaction  is  solid 
and  complete,  there  are  the  his- 
tory of  direct  force,  the  impaired 
movements,  the  slight  deformity, 
and  the  absence  of  crepitus.  In 
all  fractures  of  the  upper  end  of 
the  humerus  the  distinction  can 
be  made  from  dislocation  by  feel- 
ing the  head  of  the  bone  under 
the  acromion  and  by  noting  that 
it  does  not  move  on  rotating  the 
arm.  The  prognosis  of  these  fract- 
ures is  good. 

Treatment. — In  treating  a  case 
of  fracture  of  the  surgical  neck, 
reduce  by  traction  and  manipula- 
tion ;  if  there  is  an  impaction,  pull 
it  apart.  Take  an  internal  angular  sphnt  (PI.  5,  Fig.  6)  and 
pad  it  well,  putting  on  extra  padding  at  the  points  that  are 
to  rest  against  the  palm,  the  inner  condyle,  and  the  axillary 


Fig.  77. — Internal  angular  splint 
and  shoulder-cap  in  fracture  of  the  sur- 
gical neck  of  the  humerus. 


366 


MODERN  SURGERY. 


folds.  Lay  the  arm  and  pronated  forearm  upon  the  spHnt. 
Apply  a  padded  shoulder-cap.  Fix  the  sphnt  and  cap  in 
place  with  a  spiral  reverse  bandage  terminating  as  a  spica 
of  the  shoulder,  and  hang  the  hand  or  forearm  in  a  sling 
(Fig.  jf).  The  dressing  is  to  be  worn  for  five  weeks,  and 
the  rules  to  be  followed  in  changing  it  are  the  same  as  in 
fractures  of  the  anatomical  neck.  Motions  are  to  be  made 
after  four  weeks  to  amend  stiffness.  Another  plan  of  treat- 
ment is  the  same  as  for  fracture  of  the  anatomical  neck,  sup- 
porting the  wrist  only 
in  a  sling  so  as  to  get 
the  extending  weight 
of  the  elbow,  increasing 
this  weight  in  some 
cases  by  hanging  to  the 
elbow  a  bag  of  shot. 
In  rare  cases — those 
with  strong  anterior  pro- 
jection of  the  lower  end 
of  the  upper  fragment — 
apply  an  anterior  angu- 
lar splint  (Brinton).  In 
some  cases  where  the 
deformity  strongly  tends 
to  recur  support  by  a 
plaster-of-Paris  trough 
on  the  back  and  sides  of 
arm  and  shoulder  (Fig. 
78),  and  maintain  ex- 
tension by  weights  and 
pulleys,  the  patient  being 
kept  in  bed  (Stimson). 
Longitudinal  and  Oblique  Fracture  of  the  Head  of  the 
Humerus. — By  this  term  may  be  designated  separation  of 
the  great  tuberosity,  or  separation  of  a  portion  of  the  articular 
surface,  together  with  the  great  tuberosity,  from  the  shaft  and 
lesser  tuberosity  (Pickering  Pick,  Guthrie,  and  Ogston).  The 
cause  is  direct  violence  to  the  front  of  the  shoulder. 

Symptoms. — The  symptoms  in  longitudinal  and  oblique 
fracture  of  the  head  are  broadening  and  flattening  of  the 
shoulder  with  projection  of  the  acromion.  The  upper  frag- 
ment passes  up  and  out,  and  the  lower  fragment  passes  up 
and  in  to  rest  on  the  margin  of  the  glenoid  cavity  below 
the  coracoid.  The  elbow  is  drawn  from  the  side,  there  is 
some  shortening,  and  the  patient  cannot  abduct  his  arm.    If 


Fig.  78.— Apparatus  for  fracture  of  the  humerus  at 
any  point  above  the  condyles. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    2,6"/ 

the  elbow  be  grasped  and  held  to  the  side  and  the  arm  be 
rotated  while  the  other  hand  grasps  the  upper  fragment, 
crepitus  is  very  positive.  Examination  develops  wide  sepa- 
ration of  the  fragments.  The  deformity  cannot  be  entirely 
corrected,  because  the  biceps  tendon  gets  between  the 
fragments  (Ogston),  but  a  useful  limb  can  usually  be 
obtained. 

Trcatmc7it. — The  plan  which  gives  the  best  result  in  treat- 
ing longitudinal  and  oblique  fracture  of  the  head  is  to  place 
the  patient  on  his  back  upon  a  hard  bed  with  a  small  firm 
pillow  under  his  head,  and  to  abduct  the  arm  above  the 
head,  rotate  it  outward  so  that  the  back  of  the  hand  rests 
on  the  bed,  and  hold  it  in  place  by  sand-bags.  This  position 
should  be  maintained  for  three  weeks,  at  the  end  of  which 
period  the  fracture  can  be  dressed  for  three  weeks  more  as  a 
fracture  of  the  anatomical  neck.  If  the  patient  refuses  to  go 
to  bed,  treat  the  injury  as  a  fracture  of  the  anatomical  neck, 
padding  well  over  the  tuberosities.  The  dressings  should  be 
worn  for  six  weeks,  passive  motion  being  made  after  four 
weeks.  In  all  the  abov-e  injuries — in  fact,  in  all  fractures  of 
the  humerus — feel  at  once  for  the  pulse,  to  see  if  the  artery 
has  been  torn. 

Separation  of  the  Upper  Epiphysis. — The  epiphysis  is 
united  during  the  twentieth  year,  its  separation  being  a  rare 
accident  and  being  produced  by  direct  force. 

Syviptoins. — The  chief  symptom  in  separation  of  the  upper 
epiphysis  is  projection  of  the  upper  end  of  the  lower  frag- 
ment inward,  forward,  and  upward  beneath  the  coracoid,  and 
consequently  a  projection  of  the  elbow  backward  and  from 
the  side.  If  the  lower  fragment  passes  forward  and  not 
inward,  the  elbow  simply  passes  back.  The  upper  end  of 
the  lower  fragment  is  smooth  and  convex.  Rotation  of  the 
shaft  develops  soft  crepitus  when  the  fragments  are  in 
contact. 

The  prognosis  is  good  for  bony  union,  though  the  future 
growth  of  the  limb  may  be  impaired. 

Treatment. — The  treatment  for  separation  of  the  upper 
epiphysis  is  a  pad  in  the  axilla,  a  shoulder-cap,  binding 
the  arm  to  the  side,  and  hanging  the  hand  in  a  sling. 
Wear  the  dressing  for  six  weeks. 

2.  Fracture  of  the  Shaft  of  the  Humerus. — Fracture 
of  the  shaft  of  the  humerus  is  a  very  common  accident. 
The  cause  is  usually  direct  violence,  such  as  a  blow.  The 
fracture  may  arise  from  indirect  violence,  such  as  a  fall  upon 
the  elbow.     Muscular  action  is  not  rarely  also  a  cause,  as 


368 


MODERN  SURGERY. 


in  throwing  a  ball,  in  catching  a  tree-limb  while  falling,  or 
in  turning  another's  wrist  as  a  test  of  strength  (Treves). 

Symptoms. — The  symptoms  of  a  fractured  shaft  are  pain, 
swelling,  ecchymosis,  inability  to  move  the  arm,  mobility,  and 
distinct  crepitus.  Shortening  to  the  extent  of  three-fourths 
of  an  inch  occurs.  The  displacement  varies  with  the  situ- 
ation of  the  fracture  and  the  direction  of  the  force.  If  the 
fracture  is  above  the  insertion  of  the  deltoid,  the  lower  frag- 
ment is  pulled  up  by  the  triceps,  biceps,  and  deltoid,  and 
pulled  out  by  the  deltoid,  and  the  upper  fragment  is  pulled 
inward  by  the  arm-pit  muscles.  In  fracture  below  the  del- 
toid this  muscle  is  apt  to  pull  the  lower  end  of  the  upper 
fragment  outward,  while  the  lower  fragment  passes  inward 
and  upward  because  of  the  action  of  the  biceps  and  triceps. 
The  prognosis  is  good,  but  the  fact  should  always  be 
remembered  that  ununited  fractures  are  commoner  in  the 
humerus  than  in  any  other  bone.  Treves  believes  this  to  be 
due  to  entanglement  of  muscle  between  the  fragments,  lack  of 
fixation  of  the  shoulder-joint,  and  imperfect  elbow-support 
Hamilton  believes  that  it  is  due  to  the  facts  that  the  elbow 
soon  becomes  fixed  at  a  right  angle,  and  that  any  movement 
of  the  forearm  moves  the  seat  of  fracture,  and  not  the  elbow. 
Treatment. — Reduce  the  fracture  by  extension,  counter- 
extension,  and   manipulation.     Apply    an    internal    angular 

splint  without  the  shoulder-cap 
(Fig.  79).  If  deformity  is  not  cor- 
rected, associate  with  this  splint 
three  short  humeral  splints  in- 
stead of  the  shoulder-cap  used  in 
fractures  near  the  shoulder-joint. 
Splints  are  to  be  worn  for  six 
weeks.  Passive  movements  are 
not  to  be  made  until  the  fracture 
is  well  united  (after  six  weeks), 
for,  if  made  too  soon,  they  pre- 
dispose to  non-union,  and,  as  no 
joint  is  involved,  ankylosis  will 
not  occur.  Many  surgeons  treat 
these  fractures  by  applying  plas- 
ter-of-Paris  to  forearm,  arm,  and 
shoulder  (the  elbow  being  flexed  to  a  right  angle),  and  hang- 
ing a  weight  to  the  elbow.  Others  apply  a  trough  to  the 
arm  and  forearm  (Fig.  78).  In  any  case  in  which  it  is  im- 
possible to  obtain  and  maintain  correct  apposition  of  the 
fragments  cut  down  upon  them,  and  apply  sutures. 


Fig.    79. — Internal    angular   splint    in 
fracture  of  the  shaft  of  the  humerus. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    369 

3.  Fractures  of  the  Lower  Extremity  of  the  Humerus. 
— Tliesc  fractures  are  spoken  of  as  fractures  in,  or  in  the 
neighborhood  of,  the  elbow-joint,  and  they  include  {a)  fract- 
ure of  the  external  condyle ;  {b)  fracture  of  the  internal  con- 
dyle;  {c)  fracture  of  the  internal  epicondyle;  {d^  fracture  at 
the  base  of  the  condyles  ;  {/)  T-fracture  ;  and  (/)  epiphyseal 
separation.  In  all  injuries  of  the  elbow-joint  use  ether  while 
making  diagnosis  and  applying  first  dressing. 

Fracture  of  the  External  Condyle  of  the  Humerus. — 
A  fracture  of  the  external  condyle  runs  into  the  joint  and 
the  capitellum  is  usually  broken  off.  This  injury  occurs 
oftenest  in  children  by  falling  on  the  hand,  but  it  may  occur 
from  direct  force,  and  may  happen  to  adults. 

SyJiiptoms. — The  symptoms  of  fracture  of  the  external 
condyle  are  severe  pain,  great  swelling,  and  crepitus  (found 
on  pressing  or  moving  the  condyle  and  on  rotating  the 
radius).  Mobility  may  also  be  discovered.  A  projection  is 
felt  on  the  outer  and  posterior  surface  of  the  elbow.  The 
hand  is  supinated  and  the  forearm  is  semiflexed.  The  patient 
cannot  use  the  joint.  The  first  examination  must  be  made 
under  ether  unless  an  A'-ray  apparatus  is  accessible,  but  even 
when  we  have  a  skiagraph  of  the  part  the  first  dressing  should 
be  put  on  under  ether. 

Fracture  of  the  Inner  Epicondyle  of  the  Humerus. — 
The  inner  epicondyle  is  an  epiphysis  which  unites  during 
the  seventeenth  year.  It  not  infrequently  breaks  from  mus- 
cular action  or  from  direct  violence,  the  fracture  not  involv- 
ing the  joint.  Crepitus  and  mobility  can  be  detected.  Dis- 
placement is  slight.  The  02itcr  epicondyle  is  never  fractured 
alone. 

Fracture  of  the  Internal  Condyle  of  the  Humerus. — 
The  line  of  fracture  of  the  internal  condyle  runs  into  the 
joint,  to  the  trochlear  surface  of  the  humerus.  The  cause 
is  always  direct  violence. 

Syinptoiiis. — In  fracture  of  the  internal  condyle  the  frag- 
ment, accompanied  by  the  ulna,  goes  upward  and  backward^ 
and  when  the  forearm  is  extended  the  ulna  projects  poste- 
riorly, the  lower  end  of  the  humerus  being  felt  in  front.  The 
fragment  forms  a  projection  back  of  the  elbow.  Crepitus 
and  preternatural  mobility  can  be  found  if  swelling  is  not  too 
great.  Crepitus  is  detected  by  flexing  and  extending  the 
forearm.  The  space  between  the  condyles  is  broader  than 
normal  and  the  forearm  takes  a  bend  toward  the  ulnar  side, 
the  "  carrying  function  "  of  the  forearm  being  lost.  When  a 
person  carries  a  heavy  object,  such  as  a  bucket,  he  instinc- 

24 


370  MODERN  SURGERY. 

lively  rests  the  inner  condyle  upon  the  pelvis,  and  the  nor- 
mal deviation  of  the  forearm  outward  keeps  the  bucket  from 
striking  the  leg.  This  deviation  outward  when  the  inner 
condyle  is  against  the  ilium  gives  us  the  carrying  function. 


Fig.  8o. — Diagram  to  exhibit  the  "  carrying  function  "  of  the  forearm,  and  the  loss 
of  this  function  in  fracture  of  the  inner  condyle  of  the  humerus  :  a  and  b  show  the  normal 
relation  of  the  parts  when  carrying;  c  shows  the  alteration  of  axis  of  the  forearm  when  the 
inner  condyle  is  fractured  (after  Allis). 

In  fracture  of  the  inner  condyle  the  broken  condyle  ascends 
and  the  "  carrying  function  "  is  lost  (Fig.  80). 

Fracture  at  the  Base  of  the  Condyles  of  the  Humerus. 
— This  fracture  is  just  above  the  olecranon  and  is  on  a  higher 
level  behind  than  in  front.  The  caiLse  is  direct  force  upon  the 
olecranon. 

The  symptoms  are  loss  of  function  and  pain  from  injury  of 
the  median  or  ulnar  nerves.  Crepitus  and  mobility  are  readily 
found.  The  lower  fragment  goes  backward  and  upward  by 
the  action  of  the  triceps,  biceps,  and  brachialis  anticus.  The 
lower  end  of  the  upper  fragment  projects  in  front  of  the  joint. 
This  lesion  may  be  mistaken  for  dislocation  of  the  bones  of 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.    37 1 


the  forearm  backward.  In  fracture  the  limb  is  mobile ;  in 
dislocation,  rigid.  In  fracture  the  deformity  is  easily  reduced 
and  strongly  tends  to  recur ;  in  dislocation  the  deformity  is 
reduced  with  difficulty  and  does  not  tend  to  recur.  In  dis- 
location there  is  shortening  of  forearm  but  not  of  arm ;  in 
fracture  there  is  shortening  of  arm  but  not  of  forearm.  In 
dislocation  there  is  a  smooth  large  projection  below  the 
crease  in  front  of  the  elbow ;  in  fracture  there  is  a  sharp 
projection  above  the  crease.  In  fracture  there  is  crepitus  ;  in 
dislocation  there  is  no  crepitus.  The  diagnosis  can  be  set- 
tled by  the  Rontgen  rays. 

T-fracture  of  the  Humerus. — This  is  a  transverse  fracture 
above  the  condyles  plus  a  vertical  fracture  between  them. 
The  cause  is  violent  direct  force  applied  posteriorly. 

Symptoms. — The  symptoms  are  increase  in  breadth  of  the 
joint,  preternatural  mobility,  crepitus,  pain,  and  swelling, 
mounting  up  of  the  inner  condyle  back  of  the  elbow  on  the 
inner  side,  and  of  the  outer  condyle  back  of  the  elbow  on  the 
outer  side.  The  hand  is  supinated ;  the  forearm  semiflexed  ; 
the  carrying  function  is  lost. 

Prog-nosis  and  Treatm.ent  of  Fractures  In  or  Near 
the  Elbow -joint. — The  prognosis  for  complete  restora- 
tion of  function  is  bad,  and  in  most  of  these  fractures 
some  deformity  and  considerable  stiffness  are  inevitable. 
Callus  poured  into  a  joint  acts  like  a  stone  pushed  into 
the  crack  of  a  door:  it  limits 
or  prevents  motion.  Give 
ether  for  diagnosis  and  the 
first  dressing.  In  all  cases 
possible  use  the  ;r-rays  for 
diagnosis.  After  the  dress- 
ings are  applied  the  ,t'-rays 
will  show  if  a  displacement 
has  recurred  during  the  ap- 
plication of  the  splint.  If 
swelling  is  so  great  that  the 
surgeon  dare  not  apply  a 
splint,  let  him  rest  the  arm, 
semiflexed,  upon  a  pillow 
and  apply  lead-water  and 
■laudanum  for  a  day  or  two.  The  position  for  splinting  is  to 
be  full  supination,  which  is  obtained  by  so  placing  the  hand 
of  the  patient  that  he  could  easily  spit  into  the  palm  (Brinton). 
Apply  a  well-padded  anterior  angular  splint  (a  right-angled 
splint;  PI.  5,  Fig.   5  ;  Fig.  81).     If  posterior  projection  exists, 


-Anterior  angular  splint  for  fractures 
in  or  near  the  elbow-joint. 


372  MODERN  SURGERY. 

mould  a  pasteboard  cup  over  the  elbow  and  also  use  the 
anterior  splint,  or  apply  a  posterior  trough  without  the 
anterior  angular  splint  (Fig.  78).  In  applying  the  anterior 
angular  splint  first  fasten  the  upper  end  to  the  arm,  then 
make  extension  of  the  elbow,  and  fasten  the  lower  end 
of  the  splint  to  the  extended  forearm.  This  splint  is  to 
be  worn  for  five  weeks,  removing  it  carefully  every  third 
day.  Begin  passive  motion  at  the  end  of  the  third  week. 
Some  surgeons  oppose  the  making  of  passive  motion  so  early, 
believing  that  it  leads  to  further  formation  of  callus.  After 
the  dressings  are  removed  employ  passive  motion,  massage, 
hot  and  cold  douches,  inunctions  of  ichthyol  or  mercurial 
ointment,  iodin  locally,  corrosive  sublimate  and  iodid  of 
potassium  internally,  and  direct  the  patient  to  systematically 
use  the  arm.  Many  surgeons  at  the  end  of  the  second  week 
apply  a  Stromeyer  splint,  which  permits  the  patient  and  the 
surgeon  to  make  some  motion  by  means  of  the  screw  (Fig. 
108)  without  removing  the  dressings.  In  children  or  in  very 
stout  people  an  anterior  angular  splint  will  not  stay  in  place, 
in  which  case  the  arm  should  be  put  at  a  right  angle  and 
plaster-of- Paris  be  used.  If  in  any  case  after  four  weeks  non- 
union exists,  put  up  the  arm  in  a  plaster  splint  for  three  or 
four  weeks  more. 

Allis  warmly  advocates  treatment  in  extension.  He  holds 
that  the  extended  position  secures  the  best  circulation,  and 
if  either  condyle  is  unbroken  gives  us  a  natural  splint.  Fur- 
thermore, in  fractures  of  the  inner  condyle,  it  restores  the 
carrying  function,  which  the  flexed  position  does  not  do.  For 
one  week  after  the  accident  the  patient  stays  in  bed,  with  his 
arm  extended  upon  a  pillow.  After  swelling  subsides  the 
limb  is  wrapped  firmly  in  a  spiral  flannel  bandage  and  plaster 
is  rubbed  in  or  the  bandage  is  covered  with  adhesive  plaster. 

Some  surgeons  extend  the  limb  and  apply  an  ordinary 
plaster  bandage,  and  in  about  three  weeks  substitute  an  ante- 
rior angular  splint.  The  trouble  with  treatment  in  extension 
is  that  if  ankylosis  ensues  the  limb  is  nearly  useless.  Fur- 
thermore, it  requires  confinement  to  bed. 

Jones  of  Liverpool  thinks  that  splints  and  bandages  are 
largely  responsible  for  the  stiffness  which  so  commonly  en- 
sues upon  an  elbow  injury.  He  advocates  treatment  by  acute 
flexion  in  all  elbow  injuries  except  fracture  of  the  olecranon.. 
In  a  fracture  he  extends,  supinates,  and  flexes  to  reduce  the 
displacement.  He  maintains  flexion  by  fastening  a  bandage 
around  the  wrist  and  neck.  The  bandage  around  the  neck 
passes  through  a  rubber  tube  which  serves  to  protect  the 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    373 

neck.  The  ball  of  the  thumb  should  rest  against  the  neck. 
The  bandage  is  fastened  to  a  leather  band  around  the  wrist. 
This  position  is  maintained  from  three  to  six  weeks.'  The 
author  has  treated  a  number  of  cases  by  Jones's  method  and 
now  prefers  it  to  any  other  plan. 

Separation  of  the  lo^wer  epiphysis  of  the  humerus  is  a 
not  unusual  accident.  The  inferior  extremity  of  the  humerus 
may  be  separated,  or  the  condyles  may  be  separated  from 
each  other  and  from  the  shaft  of  the  bone. 

Symptoms.— "WiQ  symptoms  are — prominence  in  front  of 
the  joint,  caused  by  the  lower  end  of  the  shaft  of  the  hume- 
rus ;  projection  backward  of  the  olecranon ;  hand  midway 
between  pronation  and  supination.  Epiphyseal  separation 
may  retard  growth  and  produce  deformity. 

Treatment. — Jones's  position  or  anterior  angular  splint  as 
above  directed. 

Fractures  of  the  ulna  comprise  the  following  varieties  : 
(i)  fracture  of  the  coronoid  process  ;  (2)  fracture  of  the  olec- 
ranon process  ;  (3)  fracture  of  the  shaft ;  and  (4)  fracture  of 
the  styloid  process. 

Fracture  of  the  coronoid  process  of  the  ulna  is  a  rare 
injury  and  practically  occurs  only  as  a  complication  of  a 
backward  dislocation  of  the  ulna  or  in  association  with  other 
fractures. 

Symptoms. — When  fracture  of  the  coronoid  process  is 
associated  with  a  dislocation  there  is  produced  crepitus  on 
reduction,  and  it  is  found  that  the  deformity  of  the  disloca- 
tion promptly  returns  on  cessation  of  extension.  The  upper 
fragment  may  be  pulled  up  by  the  brachialis  anticus,  and 
there  exists  an  inability  to  flex  the  forearm  completely.  The 
position  is  one  of  extension  with  posterior  projection  of 
the  olecranon.  The  broken  piece  is  felt  in  front  of  the 
joint. 

Treatment. — The  treatment  is  by  an  anterior  splint  whose 
angle  is  less  than  a  right  angle ;  the  splint  is  to  be  worn  for 
four  weeks,  and  passive  motion  is  to  be  begun  in  the  third 
week.  Jones's  position  may  be  used  in  treating  such  a  case. 
A  stiff  joint  will  probably  follow. 

Fracture  of  the  olecranon  process  of  the  ulna  is  not  an 
uncommon  injury  in  adults.  Hulke  states  that  it  never 
occurs  before  the  age  of  fifteen,  but  the  writer  has  seen  in 
the  Jefferson  Hospital  a  girl  aged  fourteen  with  a  fractured 
olecranon.  The  cause  is  direct  violence  or  muscular  action. 
Only  a  small  fragment  may  be  torn  away,  or  the  greater  part 
^  Provincial  Medical  Jour.,  Dec,  1894,  and  Jan.,  1895. 


374  MODERN  SURGERY. 

of  the  olecranon  may  be  broken  off,  and  the  break  may  be 
comminuted  or  even  be  compound. 

Symptoms. — The  symptoms  of  fracture  of  the  olecranon 
are — swelling  ;  partial  flexion  of  forearm  ;  separation  of  frag- 
ments, the  upper  piece  being  pulled  up  from  half  an  inch  to 
two  inches  by  the  triceps ;  the  space  between  the  fragments 
is  increased  by  forearm  flexion  and  lessened  by  forearm  ex- 
tension ;  there  is  inability  to  extend  the  arm.  Bulging  of  the 
triceps  above  the  fragments  and  crepitus  on  approximating 
the  fragments  are  observed.  In  some  few  cases  there  is  no 
separation,  the  periosteum  being  untorn  or  the  fascial  expan- 
sions from  the  triceps  holding  the  fragments  in  apposition. 
In  such  cases  crepitus  can  be  eHcited  by  rocking  the  upper 
fragment  from  side  to  side. 

The  prognosis  is  fair,  fibrous  union  being  the  rule.  Some 
joint-stiffness  usually  occurs,  and  much  ankylosis  may  be 
unavoidable. 

Treatment. — This  fracture  calls  for  a  well-padded  anterior 
splint,  almost  but  not  quite  straight.  A  perfectly  straight 
splint  is  uncomfortable,  and,  by  opening  a  retiring  angle  be- 
tween the  fragments  and  into  the  joint,  favors  non-union  and 
ankylosis.  The  splint  should  reach  from  a  level  with  the 
axillary  margin  to  below  the  fingers.  If  the  upper  fragment 
does  not  come  in  contact  with  the  lower,  pull  it  down  by  ad- 
hesive plaster  and  fasten  the  strips  to  the  splint.  The  author 
in  one  case  employed  a  glove  to  which  strings  from  the  ad- 
hesive plaster  were  attached.  After  applying  the  splint  keep 
the  patient  in  bed  for  three  weeks.  The  danger  of  ankylosis  in 
this  fracture  is  very  great,  and,  in  case  it  occurs  in  the  posi- 
tion of  extension,  an  almost  useless  arm  results.  Pickering 
Pick  at  the  end  of  three  weeks  anesthetizes  the  patient, 
presses  his  thumb  firmly  down  upon  the  top  of  the  olec- 
ranon, puts  the  forearm  at  a  right  angle,  and  applies  an 
anterior  angular  splint  and  directs  it  to  be  worn  for  two 
weeks,  passive  motion  being  made  every  other  day.  When 
the  splint  is  removed  try  to  obtain  motion  as  previously 
directed.     Non-union  requires  wiring  of  the  fragments. 

Fracture  of  the  shaft  of  the  ulna  alone  is  most  apt  to  be 
near  the  middle,  is  always  due  to  direct  violence,  and  is  not 
unusually  compound.  An  injury  which  breaks  the  ulna  is 
very  apt  to  break  the  radius  also. 

Symptoms. — By  running  the  finger  along  the  inner  surface 
of  the  bone  there  are  detected  inequality  and  depression ; 
crepitus  and  mobility  are  easily  developed ;  there  are  pain 
and  the  evidences  of  direct  violence.     The  long  axis  of  the 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.     375 


hand  is  not  on  a  line  with  the  long  axis  of  the  forearm,  but  is 
internal  to  it.  If  deformity  exists,  it  is  due  to  the  lower  frag- 
ment passing  into  the  interosseous  space  because  of  the  action 
of  the  pronator  quadratus  muscle  ;  the  upper  fragment,  acted 
on  by  the  brachialis  anticus,  passes  a  little  forward.  The 
forearm  at  and  below  the  seat  of  fracture  is  narrower  and 
thicker  than  normal. 

Trcatuioit. — In  treating  fracture  of  the  shaft  place  the 
forearm  midway  between  pronation  and  supination,  so  as  to 
bring  the  fragments  together  and  to  obtain  the  widest  pos- 
sible interosseous  space ;  this  limits  the  danger  of  ankylosis 
in  this  space.  The  position  midway  between  pronation  and 
supination  is  marked  by  flexing  the  forearm  to  a  right  angle 
with  the  arm  and  pointing  the  thumb  to  the  nose.  Take 
two  well-padded  straight  splints,  one  long  enough  to  reach 
from  the  inner  condyle  to  below  the  fingers,  the  other  from 
the  outer  condyle  to  be- 
low the  wrist ;  place  a 
long  pad  over  the  inter- 
osseous space  on  the 
flexor  side  of  the  limb, 
and  another  on  the  exten- 
sor side  ;  apply  the  splints 
and  hang  the  arm  in  a  tri- 
angular sling  (Fig.  82). 
Passive  motion  is  to  be 
made  in  the  third  week, 

and    the  splints    are   to  be     Fig.  82.— Two  straight  splims  in  fracture  of  both 
^  bones  of  the  forearm. 

worn     lor     four     weeks. 

Fractures  of  the  ulna  can  be  treated  v^ery  efficiently  with 

plaster-of-Paris. 

Fracture  of  the  styloid  process  of  the  ulna  is  due  to 
direct  force.     The  displacement  is  obvious. 

Treatment. — In  treating  fracture  of  the  styloid  process  push 
the  fragment  back  into  place  and  use  a  Bond  splint  with  a 
compress  for  four  weeks,  or  a  plaster-of-Paris  dressing. 

Fractures  of  the  radius  include  the  following  varieties  : 
{a)  fractures  of  its  head  ;  (/?)  fractures  of  its  neck  ;  {c)  fract- 
ures of  its  shaft;  and  {d)  fractures  of  its  lower  extremity. 

Fracture  of  the  head  of  the  radius  very  rarely  occurs 
alone,  but  it  may  complicate  backward  dislocation  of  the 
radius. 

Syniptoiiis. — The  symptoms  of  fracture  of  the  head  of  the 
radius  are  crepitus  on  passive  pronation  and  supination,  and 
loss  of  voluntary  pronation  and  supination. 


3/6  MODERN  SURGERY. 

Treatment. — The  treatment  of  a  fracture  of  the  head  of  the 
radius  is  the  same  as  for  a  fracture  in  or  near  the  elbow- 
joint — namely,  an  anterior  angular  splint  for  four  or  five 
weeks,  or  placing  the  extremity  in  Jones's  position. 

Fracture  of  the  neck  of  the  radius  rarely  occurs  alone. 

Symptoms. — In  this  fracture  the  forearm  is  pronated  and 
the  patient  is  found  to  have  lost  the  power  of  voluntary  pro- 
nation and  supination.  Under  forced  pronation  and  supina- 
tion it  will  be  noted  that  the  head  of  the  radius  does  not 
move  and  crepitus  is  felt.  The  lower  fragment,  being  pulled 
upward  and  forward  by  the  biceps,  can  be  felt  in  front  of  the 
elbow-joint. 

Treatment. — The  treatment  for  fracture  of  the  neck  of  the 
radius  is  the  same  as  for  fracture  of  the  elbow-joint — namely, 
an  anterior  angular  splint  or  Jones's  position. 

Fracture  of  the  shaft  of  the  radius  is  far  commoner 
than  fracture  of  the  shaft  of  the  ulna.  It  may  occur  above 
or  below  the  insertion  of  the  pronator  radii  teres  muscle.  It 
may  arise  from  either  direct  or  indirect  force.  Fracture  of 
the  shaft  of  the  ulna  frequently  exists  as  a  result  of  the  same 
accident. 

Fracture  of  the  Radius  above  the  Insertion  of  the 
Pronator  Radii  Teres  Muscle. — Symptoms. — The  upper 
fragment  is  drawn  forward  by  the  biceps  and  is  fully  supi- 
nated  by  the  supinator  brevis.  The  lower  fragment  is  fully 
pronated  by  the  pronator  quadratus  and  pronator  radii  teres, 
and  its  upper  end  is  pulled  into  the  interosseous  space. 
There  are  crepitus,  mobility,  pain,  narrowing  and  thickening 
of  the  forearm  below  the  seat  of  fracture,  and  loss  of  the 
power  of  pronation  and  supination.  The  head  of  the  bone 
is  motionless  during  passive  pronation  and  supination.  The 
hand  is  prone. 

Treatment. — In  treating  this  fracture  do  not  put  the 
forearm  midway  between  pronation  and  supination,  as  this 
position  will  not  bring  the  fragments  into  contact,  the  upper 
fragment  remaining  flexed  and  supinated.  To  bring  the 
lower  fragment  in  contact  with  the  upper,  flex  and  fully 
supinate  the  forearm.  Put  the  arm  upon  an  anterior  angular 
splint  for  four  weeks,  and  make  passive  motion  in  the  third 
week. 

Fracture  of  the  Radius  below  the  Insertion  of  the 
Pronator  Radii  Teres  Muscle. — In  this  variety  of  fracture 
the  upper  fragment  is  acted  on  by  the  biceps,  the  supinator 
brevis,  and  the  pronator  radii  teres,  and  it  remains  about 
midway  between  pronation  and  supination,  passing  forward 


DISEASES  AND  INJURIES    OF  BONES  AND  JOINTS.     377 

and  also  into  the  interosseous  space.  The  lower  fragment 
is  acted  on  by  the  supinator  longus  and  the  pronator  quad- 
ratus,  the  latter  being  the  more  powerful  of  the  two,  and  the 
lower  fragment  is  moderately  pronated,  its  upper  extremity 
being  thrown  into  the  interosseous  space.  Other  symptoms 
are  identical  with  those  of  fracture  above  the  insertion  of  the 
pronator  radii  teres. 

Treatment. — In  treating  fracture  below  the  pronator  radii 
teres  the  forearm  is  flexed  and  is  placed  midway  between 
pronation  and  supination  ;  interosseous  pads  and  two  straight 
splints  are  applied  as  for  fracture  of  the  ulna  (Fig.  82).  The 
splints  are  worn  for  four  weeks,  and  passive  motion  is  made 
in  the  third  week.  Plaster-of- Paris  is  a  most  satisfactory 
dressing. 

Fracture  of  the  shafts  of  both  bones  of  the  forearm  is 
not  frequently  seen.     It  is  caused  by  direct  or  indirect  force. 

Symptoms. — In  fractures  of  both  bones  of  the  forearm  the 
hand  is  pronated  and  the  lower  two  fragments  come  together 
and  are  drawn  upward  and  backward  or  upward  and  forward 
by  the  combined  force  of  flexor  and  extensor  muscles,  short- 
ening being  manifest  and  the  projection  of  the  lower  frag- 
ments being  detected  on  either  the  dorsal  or  the  flexor  sur- 
face of  the  forearm.  The  upper  fragment  of  the  ulna  is 
somewhat  flexed  by  the  brachialis  anticus  ;  the  upper  frag- 
ment of  the  radius  is  flexed  by  the  biceps  and  is  pronated 
and  drawn  toward  the  ulna  by  the  pronator  radii  teres.  The 
forearm  is  narrower  than  it  should  be  (the  ends  of  the  frag- 
ments having  passed  into  the  interosseous  space)  and  is 
thicker  than  normal  (the  contents  of  the  interosseous  space 
having  been  forced  out).  Crepitus,  mobility,  pain,  and 
inequality  exist,  the  power  of  rotation  is  lost,  and  on  pas- 
sive rotation  the  head  of  the  radius  does  not  move.  The 
forearm  is  prone  and  semiflexed. 

Treatment. — The  treatment  requires  two  straight  splints 
and  two  interosseous  pads,  the  forearm  flexed  to  a  right 
angle  and  placed  midway  between  pronation  and  supination 
(Fig.  82).  The  splints  are  worn  for  four  weeks,  and  passive 
motion  is  made  in  the  third  week.  Instead  of  this  a  plaster- 
of-Paris  dressing  can  be  used. 

Fracture  of  the  Lo-wer  Extremity  of  the  Radius. — Bar- 
ton's fracture  is  oblique,  starts  A\'ithin  half  an  inch  of  the 
joint,  and  runs  into  the  joint.  Colles's  fracture  is  a  trans- 
verse or  nearly  transverse  fracture  of  the  lower  end  of  the 
radius,  between  the  limits  of  one-quarter  of  an  inch  and  one 
and  a  half  inches  above  the  wrist-joint,  the  lower  fragment 


378  MODERN  SURGERY. 

mounting  upon  the  dorsum  of  the  upper  fragment.  Cones' s 
fracture,  a  very  common  injury,  is  met  with  most  frequently 
in  those  beyond  the  age  of  forty,  and  oftener  in  women  than 
in  men.  It  is  due  to  transmitted  force  (a  fall  upon  the  palm 
of  the  pronated  hand),  the  force  being  received  by  the  ball 
of  the  thumb  and  passing  to  the  carpal  bones  and  the  edge 
of  the  radius  ;  a  fracture  begins  posteriorly  rather  than  ante- 
riorly, the  force  driving  the  fragment  upon  the  dorsal  surface 
of  the  radius,  the  carpus  and  lower  fragment  moving  upward 
and  outward.  The  fragments  are  not  unusually  impacted. 
In  the  author's  experience  dislocation  of  the  lower  end  of 
the  ulna  is  a  frequent  complication,  which  arises  from  a  fract- 
ure of  the  ulnar  styloid  or  tearing  off  of  the  internal  lateral 
ligament  of  the  wrist.  Some  hold  that  this  fracture  is  due 
to  sudden  traction  upon  the  anterior  ligaments,  which  drag 
upon  the  bone  and  break  it  at  the  point  where  the  cancellous 
end  of  the  radius  joins  the  compact  shaft. 

Symptoms. — In  Colles's  fracture  the  hand  is  abducted 
(drawn  to  the  radial  side  of  the  forearm)  and  pronated, 
the  head  of  the  ulna  is  prominent,  the  styloid  process  of 
the  radius  is  raised,  and  the  lower  fragment,  which  mounts 
on  the  back  of  the  lower  end  of  the  upper  fragment,  causes 
a  dorsal  projection,  termed  by  Liston  the  "  silver-fork  de- 
formity." The  lower  end  of  the  upper  fragment  can  be  felt 
beneath  the  flexor  tendons  above  the  wrist.  The  position 
in  deformity  is  produced  by  the  force.  Some  consider  it 
is  maintained  by  the  action  of  the  supinator  longus  and  the 
flexor  and  extensor  muscles,  but  particularly  by  the  exten- 
sors of  the  thumb.  Pilcher  has  demonstrated  the  fact  that 
in  this  fracture  a  portion  of  the  dorsal  periosteum  is  untorn, 
and  this  untorn  portion  acts  as  a  binding  band  to  hold  the 
fragments  in  deformity.  Pronation  and  supination  are  lost. 
In  this  fracture  the  hand  can  be  greatly  hyperextended 
(Maisonneuve's  symptom).  Crepitus,  which  is  best  obtained 
by  alternate  hyperextension  and  flexion,  can  be  secured 
unless  swelling  is  great  or  impaction  exists.  Crepitus  on 
side  movements  is  rarely  obtainable.  Impaction  may  greatly 
modify  the  deformity,  though  displacement  generally  exists 
to  some  extent,  and  the  fragments  do  not  ride  easily  on  each 
other.  The  styloid  process  of  the  ulna  may  be  broken,  or 
the  inferior  radio-ulnar  articulation  may  be  separated.  This 
latter  complication  allows  the  lower  fragment  to  roll  freely 
upon  the  upper,  and  the  characteristic  silver-fork  deformity 
does  not  appear.  If  the  styloid  process  of  the  ulna  is  broken, 
pressure  over  it  causes  great  pain.     If  a  person  in  falling 


DISEASES  A  AD   EV/CA'/ES   OE  BONES  AND  JOINTS.     379 

Strikes  the  back  of  the  hand  and  a  fracture  of  the  radius 
occurs,  the  lower  fragment  is  driven  upon  the  front  surface 
of  the  upper  fragment  and  is  felt  under  the  flexor  tendons  at 
the  wrist.  An  elaborate  study  of  fracture  of  the  radius  with 
forward  displacement  of  the  lower  fragment  has  been  recently 
published  by  John  B.  Roberts/ 

Trcatniciit. — In  treating   Colles's  fracture   reduce  the  de- 


FiG.  83. — Levis's  radius-splints,  right  and  left,  for  fracture  of  the  lower  end  of  the  radius. 


formity  by  hyperextension  to  unlock  the  fragments  and 
relax  the  dorsal  periosteum,  followed  by  longitudinal  trac- 
tion to  separate  the  fragments, 
and  by  forced  flexion  to  force 
them  into  position.  This  formula 
was  introduced  many  years  ago 
by  the  late  R.  J.  Levis.  The 
extremity  can  be  placed  upon  a 
Levis  splint  (Fig.  83),  the  position 
maintaining  reduction  and  the 
tense  extensor  tendons  giving 
dorsal  support.  Some  surgeons 
use  Gordon's  pistol  -  shaped 
splint.  The  favorite  splint  in 
Philadelphia  practice  is  Bond's. 
It  places  the  hand  in  a  natural 
position  of  rest  (semiflexion  of 
the  fingers,  semi-extension  of  the  wrist,  and  deviation  of  the 
hand  toward  the  ulna).     Two  pads  are  used :  a  dorsal  pad 

^  Am.  Joitr.  Med.  Sci.,  Jan.,  1S97. 


Fig.  84. — Bond's  splint  in   Colles's 
fracture. 


380  MODERN  SURGERY. 

which  oveHies  the  lower  fragment,  and  a  pad  for  the  flexor 
surface  which  overHes  the  lower  end  of  the  upper  fragment. 
A  bandage  is  appUed,  the  thumb  and  fingers  being  left  free 
(Fig.  84;  PI.  5,  Fig.  7).  Passive  motion  is  begun  upon  the 
fingers  in  three  or  four  days,  and  upon  the  wrist  during  the 
second  week.  The  splint  is  removed  in  three  weeks,  and 
a  bandage  is  worn  for  a  week  or  two  more  because  of 
the  swelling.  In  applying  the  Bond  splint,  do  not  pull 
the  hand  too  much  up  on  the  block,  or  the  fracture  will 
unite  with  a  projection  upon  the  flexor  surface  of  the 
extremity  and  the  tendons  of  the  wrist  will  be  apt  to  be 
caught  in  the  callus.  If  a  stiff  joint  and  limited  tendon- 
motion  eventuate  from  the  fracture,  use  massage,  frictions, 
sorbefacient  ointments,  tincture  of  iodin,  electricity,  and  hot 
and  cold  douches,  or  give  ether  and  forcibly  break  up  ad- 
hesions. Undoubtedly  more  or  less  stiffness  often  follows 
Colles's  fracture,  and  some  very  able  surgeons  have  been  so 
impressed  with  the  frequency  of  its  occurrence  that  they 
have  dispensed  with  the  use  of  a  splint.  Sir  Astley  Cooper 
long  ago  spoke  of  placing  the  arm  in  a  sling  as  proper 
treatment  for  fracture  of  the  radius.  Moore  of  Rochester 
applied  a  cylindrical  compress  over  the  ulna,  held  in  place 
for  six  hours  with  adhesive  plaster,  then  cut  the  plaster, 
placed  the  forearm  in  a  sling,  and  let  the  hand  hang  over 
the  edge  of  the  sling.  Pilcher  applies  a  band  of  adhesive 
plaster  around  the  wrist  and  supports  the  wrist  in  a  sling. 
Storp  says  that  dispensary  patients  are  apt  to  disarrange 
this  dressing.^  He  wraps  a  piece  of  rubber  plaster  four 
inches  wide  around  the  wrist,  and  places  a  second  piece 
around  the  first  so  arranged  as  to  form  a  fold  over  the 
radius  ;  an  opening  is  made  through  the  fold  for  the  passage 
of  a  sling.  In  ten  days  the  plaster  is  removed  and  the  fore- 
arm is  carried  in  a  sling. 

Fracture  of  both  the  Radius  and  Ulna  near  the  Wrist. 
— Colles's  fracture  may  be  complicated  by  a  fracture  of  the 
ulna  other  than  of  its  styloid  process. 

Symptoms. — In  fracture  of  the  radius  and  ulna  near  the 
wrist  the  lower  ends  of  the  upper  fragments  come  together, 
the  upper  fragment  of  the  radius  is  pronated,  and  the  lower 
fragment  of  the  radius  is  drawn  up.  Pain,  crepitus,  mobility, 
shortening,  and  loss  of  function  exist. 

Treatment. — A  fracture  of  the  radius  and  ulna  requires  the 
use  of  the  Bond  splint,  as  for  Colles's  fracture. 

Separation  of  the  Lower  Radial  Epiphysis. — This  acci- 

1  Arch.  f.  klin.  Chir.,  liii. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    38 1 

dent  occurs  in  children  from  falling  upon  the  palm  of  the 
hand.     It  never  happens  after  the  twentieth  year. 

Syniptojiis. — In  separation  of  the  lower  radial  epiphysis 
the  lower  fragment  mounts  upon  the  upper  and  produces  a 
dorsal  projection  like  Colles's  fracture,  but  the  hand  does  not 
deviate  to  the  radial  side.  The  deformity  resembles  that  of 
a  backward  carpal  dislocation,  but  is  differentiated  from  dis- 
location by  the  unaltered  relation  in  the  fracture  between  the 
st}'loid  processes  and  the  carpal  bones. 

Treatment. — The  treatment  in  separation  of  the  lower 
radial  epiphysis  consists  of  the  use  of  a  Bond  splint,  as  in 
Colles's  fracture. 

Fractures  of  the  carpus  are  not  frequent,  and  they  are 
usually  compound.     The  cause  is  violent  direct  force. 

Syjiiptcvns. — Fractures  of  the  carpus  are  indicated  by  pain, 
swelling,  evidences  of  direct  force,  sometimes  crepitus,  loss 
of  power  in  the  hand,  and  a  very  little  displacement. 

Treatment. — Many  compound  comminuted  fractures  of  the 
carpus  require  amputation.  In  an  ordinary  compound  fract- 
ure, asepticize,  drain,  dress  with  antiseptic  gauze  and  a  plas- 
ter-of-Paris  bandage,  cutting  trap-doors  in  the  plaster  over 
the  ends  of  the  drainage-tube.  In  a  simple  fracture  use  lead- 
water  and  laudanum  for  a  few  days.  Dress  the  hand  upon  a 
well-padded  straight  palmar  splint  (PI.  5,  Fig.  10)  reaching 
from  beyond  the  fingers  to  the  middle  of  the  forearm,  and 
place  the  hand  and  forearm  in  a  sling.  The  splint  is  worn 
for  four  weeks,  and  passiv'e  motion  of  the  wrist  is  begun  in 
the   second  week. 

Fracture  of  the  Metacarpal  Bones. — Metacarpal  fracture 
is  very  common.  One  or  more  bones  may  be  broken.  The 
first  metacarpal  bone  is  oftenest  broken  ;  the  third  is  rarely 
broken  (Hulke).     The  cause  is  direct  or  indirect  force. 

Symptoms. — The  signs  of  a  metacarpal  fracture  are — dorsal 
projection  of  the  upper  end  of  the  lower  fragment  and  the 
lower  end  of  the  upper  fragment ;  pain  ;  crepitus ;  and  often 
evidences  of  direct  violence. 

Treatment. — To  treat  a  fracture  of  a  metacarpal  bone  re- 
duce by  extension  ;  place  a  large  ball  of  oakum,  cotton,  or 
lint  in  the  palm  to  maintain  the  natural  rotundity,  and  apply 
a  straight  palmar  splint  like  that  used  in  fractures  of  the  car- 
pus (PI.  5,  Fig.  10).  It  may  be  necessary  to  apply  a  compress 
over  the  dorsal  projection.  The  duration  of  treatment  is  three 
weeks,  and  passive  motion  is  begun  after  two  weeks.  A  plas- 
ter-of-Paris  dressing  is  often  used. 

Fractures  of  the  Phalanges. — The  phalanges  are  often 


382  MODERN  SURGERY. 

broken.  The  fracture  may  be  compound.  The  cause  usually 
is  direct  force. 

Symptoms. — Fracture  of  the  phalanges  is  indicated  by 
pain,  bruising,  crepitus,  and  mobility,  with  very  little  or 
no  displacement. 

Treatment. — If  the  middle  or  distal  phalanx  is  broken, 
mould  on  a  trough-like  splint  of  gutta-percha  or  of  paste- 
board, which  splint  need  not  run  into  the  palm.  If  the 
proximal  phalanx  is  broken,  run  the  splint  into  the  palm  of 
the  hand.  Make  the  splint  of  gutta-percha,  pasteboard,  wood, 
or  leather.  The  splint  is  worn  three  weeks.  A  sling  must 
be  worn,  otherwise  the  finger  will  constantly  be  knocked  and 
hurt.  Some  cases  require  a  dorsal  as  well  as  a  palmar  splint. 
These  cases  are  dressed  most  satisfactorily  with  a  silicate- 
of-sodium  or  plaster-of- Paris  bandage. 

Fracture  of  the  femur  is  a  very  common  injury.  The 
divisions  of  the  femur  are  (i)  the  upper  extremity;  (2)  the 
shaft ;  and  (3)  the  lower  extremity. 

I.  Fractures  of  the  upper  extremity  of  the  femur  are 
divided  into  (a)  intracapsular ;  {b)  extracapsular ;  {c)  of  the 
great  trochanter ;  and  (d)  epiphyseal  separation  (either  of 
the  great  trochanter  or  the  head). 

Intracapsular  Fracture  of  the  Femur. — This  fracture  of 
the  neck  is  transverse  or  only  slightly  oblique,  and  is  not 
unusually  impacted.  The  cause  is  often  slight  indirect  force, 
of  the  nature  of  a  twist,  acting  upon  a  person  of  advanced 
years  (more  often  a  woman  than  a  man),  but  not  unusually 
a  fall  upon  the  great  trochanter  is  the  cause.  A  fall  upon  the 
knees,  a  trip,  or  an  attempt  to  prevent  a  fall  may  produce  this 
fracture.  It  more  often  happens  that  the  fall  is  due  to  the 
fracture  than  the  fracture  arises  from  the  fall.  Intracapsular 
fracture  is  never  caused  by  direct  force  unless  it  is  due  to 
gunshot  violence.  The  aged  are  more  liable  to  intracapsular 
fracture  than  the  young  or  the  middle-aged,  because,  first, 
the  angle  which  the  neck  forms  with  the  axis  of  the  femur 
becomes  less  obtuse  with  advancing  years,  and  may  even  form 
a  right  angle ;  this  change  is  more  pronounced  in  women 
than  in  men ;  secondly,  the  compact  tissue  becomes  thinned 
by  absorption,  the  cancelli  diminish,  the  spaces  between  them 
enlarge,  the  bony  portions  of  the  cancellous  portion  are 
thinned  or  destroyed,  and  the  cancellous  structure  becomes 
fatty  and  degenerated.  Sutton  has  shown  that  in  very  rare 
cases  this  fracture  may  occur  in  the  young,  even  before  the 
union  of  the  epiphyses.  Stokes  follows  Gordon  of  Belfast 
in  classifying  fractures  of  the  femoral  neck.    He  divides  them 


DISEASES  AXD   INJURIES   OF  BONES  AND  JOINTS.    383 

into  intracapsular  and  extracapsular,  and  subdivides  intracap- 
sular fractures  into  fracture  with  penetration  of  cervix  into 
head ;  fracture  with  reciprocal  penetration ;  intraperiosteal 
fracture  at  junction  of  cervix  and  head;  intraperiosteal  fract- 
ure of  center  of  cervix  ;  extraperiosteal  fracture,  with  lacera- 
tion of  cervical  ligaments.  The  last-named  fracture  is  the 
most  common.  The  first  four  forms  may  unite  by  bone,  the 
fifth  form  will  not  because  of  non-apposition,  lack  of  nutrition, 
effusion  of  blood,  synovitis,  or  interstitial  absorption.'  Stokes 
claims  that  we  may  have  penetration,  but  not  impaction. 

Symptoms. — In  intracapsular  fracture  there  is  usually 
shortening  to  the  extent  of  from  half  an  inch  to  an  inch; 
but  in  some  cases  no  shortening  can  be  detected.  Shorten- 
ing of  a  quarter  of  an  inch  does  not  count  in  diagnosis,  for, 
as  Hunt  shows,  one  limb  is  often  naturally  a  little  shorter 
than  the  other.  If  the  reflected  portion  of  the  capsule  is  not 
torn,  the  shortening  is  trivial  in  amount  or  is  entirely  absent. 
In  some  cases  shortening  gradually  or  suddenly  increases 
some  little  time  after  the  accident.  This  is  due  to  separation 
of  a  penetration,  tearing  of  the  previously  unlacerated  fibrous 
synovial  reflection,  or  restoration  of  muscular  strength  after 
a  paresis.  A  gradually  increasing  shortening  arises  from  ab- 
sorption of  the  head  of  the  bone.  Shortening  is  due  chiefly 
to  pulling  up  of  the  lower  fragment  by  the  hamstrings,  the 
glutei,  and  the  rectus. 

Pain  is  usually  present  in  front,  posteriorly,  and  to  the 
side.  The  area  of  pain  is  localized,  and  motion  or  pressure 
greatly  increases  the  suffering. 

Evcrsion  exists,  spoken  of  as  "  helpless  eversion,"  though 
in  a  very  few  instances  the  patient  can  still  invert  the  leg. 
This  eversion  is  due  to  the  force  of  gravity,  the  limb  rolling 
outward  because  the  line  of  gravity  has  moved  externally. 
That  eversion  is  not  due  to  the  action  of  the  external  rotator 
muscles,  as  was  taught  by  Astley  Cooper,  is  proved  by  the 
fact  that  when  a  fracture  happens  in  the  shaft  below  the  in- 
.sertion  of  these  muscles  the  lower  fragment  still  rotates  out- 
ward. This  is  further  demonstrated  by  the  considerations 
that  the  internal  rotators  are  more  powerful  than  the  exter- 
nal, that  some  patients  can  still  invert  the  limb,  and  that 
eversion  persists  during  anesthesia.^  In  some  unusual  cases 
inversion  attends  the  fracture.  Inversion,  if  it  exists,  is  due 
to  the  fact  that  the  limb  was  adducted  and  inverted  at  the 
time  of  the  accident,  and  after  the  accident  it  remains  in  this 

1  Stokes,  in  Brit.  JMed.  Jotir.,  Oct.  12,  1895. 
^  Edmund  Owens:  A  Manual  of  Anatomy. 


384  MODERN  SURGERY. 

position  (Stokes).  Besides  shortening  and  eversion,  the  leg- 
is  somewhat  flexed  on  the  thigh  and  the  thigh  on  the  pel- 
vis, the  extremity  when  rolled  out  resting  upon  its  outer  sur- 
face.    Abduction  is  commonly  present. 

Loss  of  power  is  a  prominent  symptom :  the  limb  can 
rarely  be  raised  or  inverted ;  although  in  rare  cases,  when 
the  fibrous  synovial  envelope  is  untorn,  the  patient  may  stand 
or  even  take  steps.  Pain  is  usually  trivial  except  upon  mo- 
tion, when  it  may  be  localized  in  the  joint.  In  some  cases  the 
pain  is  violent.  Crepitus  often  cannot  be  found,  either  be- 
cause the  fragments  cannot  be  approximated,  because  pene- 
tration exists,  or  because  they  are  greatly  softened  by  fatty 
change.  To  obtain  crepitus  the  front  of  the  joint  must  be 
examined  while  the  limb  is  extended  and  rotated  inward. 
But  why  try  to  obtain  crepitus  ?  The  diagnosis  is  readily 
made  without  it ;  in  many  cases  it  cannot  be  detected,  and 
the  endeavor  to  obtain  it  inflicts  pain  and  may  produce 
damage.  These  fractures  offer  a  not  very  flattering  chance 
of  repair,  and  efforts  to  find  crepitus  may  produce  serious 
damage. 

Altered  Arc  of  Rotation  of  the  Great  Trochanter  (Desault's 
sign). — The  pivot  on  which  the  great  trochanter  revolves  is 
no  longer  the  acetabulum,  and  the  great  trochanter  no  longer 
describes  the  segment  of  a  circle,  but  rotates  only  as  the  apex 
of  the  femur,  which  rotates  around  its  own  axis.  It  is  need- 
less to  try  to  obtain  this  sign  ;  to  do  so  inflicts  violence  on  the 
parts. 

Relaxation  of  the  fascia  lata  (Allis's  sign)  simply  means 
shortejting.  The  fascia  lata  is  attached  to  the  ilium  and  the 
tibia  (iliotibial  band),  and  when  shortening  brings  the  tibia 
nearer  to  the  ilium  this  band  relaxes  and  permits  one  to  push 
more  deeply  inward  on  the  injured  side,  between  the  great 
trochanter  and  the  iliac  crest,  and  near  the  knee  above  the 
outer  condyle,  than  on  the  sound  side.  In  this  examination 
each  limb  should  be  adducted.  Allis  has  pointed  out  another 
sign  :  when  the  patient  is  recumbent  the  sound  thigh  cannot 
be  raised  to  the  perpendicular  without  flexing  the  leg ;  the 
injured  thigh  can  be.  Lagoria's  sign  is  a  relaxation  of  the 
extensor  muscles. 

Ascent  of  the  Great  Trochanter  above  Nelaton's  Line. — This 
line  is  taken  from  the  anterior  superior  iliac  spine  to  the  most 
prominent  part  of  the  ischial  tuberosity  (Fig.  85).  In  health 
the  great  trochanter  is  below,  and  in  intracapsular  fracture  it 
is  above,  this  line. 

Relation  of  the  Trochanter  to  Bryant's  Triangle  (Fig.  85). — 


DISEASES  AXD   IXJL'RIES   OF  BONES  AND  JOINTS.    385 

Place  the  patient  recumbent,  carry  a  line  around  the  body  on 
a  level  with  the  anterior  superior  spines,  draw  a  line  from  the 
anterior  iliac  spine  on  each  side  to  the  summit  of  the  corre- 
sponding great  trochanter,  and  measure  the  base  of  the  tri- 
angle from  the  great  trochanter  to  the  perpendicular  line 
from  the  spine  to  determine  the  amount  of  ascent.  The  dif- 
ference in  measurement  between  the  two  sides  shows  the 
amount  of  ascent  of  the  trochanter  ;  that  is,  shows  the  extent 
of  shortening. 

Morris's  mcasurcvicnt  shows  the  extent  of  inward  displace- 
ment.   Measure  from  the  median  line 
of  the  body  to  a  perpendicular  line 
drawn    through    the   trochanter  on 
each  side  of  the  body. 

Diagnosis. — Intracapsular  fracture 
without  separation  of  the  fragments 
may  be  mistaken  for  a  mere  contu- 
sion, and  the  diagnosis  may  continue 
obscure  unless  the  fragments  sepa-        Fig.  85.— a  c  d,  Bryant's  iiio- 

.  T  c  c  t.'  ■  J-        •  femoral  triangle  ;   A  B,  Nelaton's 

rate.     Loss  ot  tunction  in  contusion     une  (Owen). 
is    rarely   complete    or    prolonged, 

although  occasionally  the  head  of  the  bone  is  absorbed. 
Early  in  a  contusion  and  possibly  throughout  the  case,  there 
is  no  alteration  between  the  relation  of  the  spine  of  the  ilium 
and  the  trochanter,  and  no  shortening.  Contusion  of  a  rheu- 
matic joint  leads  to  much  difficulty  in  diagnosis.  Intracap- 
sular fracture  may  be  confused  with  extracapsular  fracture  or 
with  a  dislocation  of  the  hip-joint.  Extracapsular  fracture, 
which  is  common  in  advanced  life,  but  is  met  with  in  middle 
life  or  even  occasionally  in  the  young,  results  usually  from 
great  violence  over  the  great  trochanter;  if  non-impacted, 
there  are  noted  shortening  of  from  one  and  a  half  to  three 
inches,  crepitus  over  the  great  trochanter,  and  usually,  but 
not  invariably,  eversion  ;  if  impacted,  there  is  less  eversion, 
crepitus  is  almost  or  entirely  absent,  and  the  shortening  is 
limited  to  about  an  inch.  Great  tenderness  exists  over  the 
great  trochanter  in  both  impacted  and  non-impacted  fract- 
ures. The  extensor  muscles  are  relaxed.  In  dislocation  on 
the  dorsum  of  the  ilium  the  patient  is  usually  a  strong  young 
adult.  There  is  a  history  of  forcible  internal  rotation.  There 
are  inversion  (the  ball  of  the  great  toe  resting  on  the  instep 
of  the  sound  foot),  rigidity,  ascent  of  the  bone  above  Nela- 
ton's line,  and  shortening  of  from  one  to  three  inches.  The 
head  of  the  bone  is  felt  on  the  dorsum  of  the  ilium,  and  the 
trochanter  mounts  up  toward  the  spine  of  the  ilium,  and 

25 


386  MODERN  SURGERY. 

pressure  upon  it  causes  no  pain.  In  dislocation  into  the 
thyroid  notch  there  is  possibly  eversion,  but  it  is  Hnked 
with  lengthening. 

\vl  fracture  of  the  brim  of  the  acetabulum  there  is  shorten- 
ing which  occurs  on  the  removal  of  extension,  inversion, 
retained  power  of  everting  the  limb,  abduction,  retained 
power  of  adduction,  flexion  of  knee,  head  of  bone  drawn 
up  and  back  with  the  acetabular  fragment  (Stokes).  Crep- 
itus, which  is  most  distinctly  appreciated  by  a  hand  resting 
on  the  ilium.  In  fracture  of  the  fundus  of  the  acetabulum 
there  is  shortening,  and  the  head  of  the  bone  enters  the  pel- 
vis (Stokes). 

Prognosis. — The  prognosis  is  not  very  favorable.  Old 
people  not  unusually  die.  Many  surgeons  have  maintained 
that  bony  union  never  occurs,  but  it  certainly  does  sometimes 
take  place.  Stokes  holds  that  bony  union  is  possible  in 
fractures  with  penetration  and  even  in  fractures  without 
penetration  when  the  fracture  is  within  the  periosteum.^ 
Non-union  is  not  unusual.  Permanent  shortening  to  some 
degree  is  inevitable,  and  the  function  of  the  joint  is  sure  to 
be  more  or  less  impaired.  It  will  be  found  necessary  in  many 
cases  for  the  patient  to  always  employ  support  in  walking. 

Treatment. — In  treating  a  very  feeble  person  for  intracap- 
sular fracture  make  no  attempt  to  obtain  union.  Keep  the 
patient  in  bed  for  two  weeks,  give  lateral  support  by  sand- 
bags, tie  around  the  ankle  a  fillet,  to  which  attach  a  weight 
of  a  few  pounds,  and  hang  the  weight  over  the  foot-board 
of  the  bed.  When  pain  and  tenderness  abate,  order  the 
patient  to  get  into  a  reclining-chair,  and  permit  him  very  soon 
to  get  about  on  crutches.  If  hypostatic  congestion  of  the 
lungs  sets  in,  if  bed-sores  appear,  if  the  appetite  and  diges- 
tion utterly  fail,  or  if  diarrhea  persists,  abandon  attempts  at 
■cure  in  any  case  and  secure  for  the  sufferer  sunshine  and 
fresh  air,  simply  immobilizing  the  fracture  as  thoroughly  as 
possible  by  means  of  pasteboard  splints.  In  the  vast  major- 
ity of  patients,  no  matter  how  old,  undertake  treatment.  We 
may  be  forced  to  abandon  it,  but  should  at  least  attempt  to 
obtain  a  cure.  If  it  is  determined  to  treat  the  case,  com- 
bine extension  with  lateral  support  by  means  of  sand-bags 
and  the  extension  apparatus  originally  devised  by  Gurdon 
Buck.  The  extension  should  be  gentle,  never  forcible.  It 
is  not  wise  to  pull  apart  a  penetration.  Place  the  subject 
on  a  firm  mattress,  and  if  the  patient  be  a  man,  shave  the 
leg.     Cut  a  foot-piece  out  of  a  cigar-box,  perforate  it  for 

1  See  the  masterly  paper  of  Stokes,  before  quoted. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    387 

a  cord,  wrap  it  with  adhesive  plaster  as  shown  on  Plate  5, 
Figs.  15  and  16,  run  the  weight-cord  through  the  opening  in 
the  wood,  and  fasten  a  piece  of  plaster  on  each  side  of  the 
leg,  from  just  below  the  seat  of  fracture  to  above  the  malleo- 
lus (PI.  5,  Fig.  14).  The  plaster  is  guarded  from  sticking  to 
the  malleoli  by  having  another  piece  stuck  to  it  at  each  of 
these  points.  Apply  an  ascending  spiral  reverse  bandage 
over  the  plaster  to  the  groin  (Fig.  86).  and  finish  the  band- 
age by  a  spica  of  the  groin.  Slightly  abduct  the  extremity. 
Put  a  brick  under  each  leg  of  the  bed  at  its  foot,  thus 
obtaining  counter-extension  by  the  weight  of  the  body. 
Run  a  cord  over  a  pulley  at  the  foot  of  the  bed,  and  get 
extension  by  the  use  of  weights.  From  ten  to  fifteen  pounds 
will  probably  be  necessary  at  first,  but  after  a  day  or  two 
from  six  to  eight  pounds  will  be  found  sufficient  (rememb'er 
that  a  brick  weighs  about  five  pounds).  Make  a  bird's-nest 
pad  of  oakum  for  the  heel.    Take  two  canvas  bags,  one  long 


Fig.  86. — Adhesive  plaster  applied  to  make  extension.     It  should  be  carried  up  higher  to  a 
point  just  below  the  seat  of  fracture. 

enough  to  reach  from  the  crest  of  the  ilium  to  the  malleolus, 
the  other  long  enough  to  reach  from  the  perineum  to  the 
malleolus.  Fill  the  bags  three-quarters  full  of  dry  sand, 
sew  up  their  ends,  cover  the  bags  with  slips,  and  put  the 
bags  in  place  in  order  to  correct  eversion.  The  slips  may 
be  changed  everj^  third  or  fourth  day.  The  bowels  are  to 
be  emptied  and  the  urine  is  to  be  voided  in  a  bed-pan, 
unless  using  a  fracture-bed.  Maintain  extension  for  five  or 
six  weeks,  then  mould  pasteboard  splints  upon  the  part,  and 
keep  the  patient  in  bed  for  three  or  four  weeks  more.  In 
from  eight  to  ten  weeks  after  the  accident  the  patient  may 
get  about  on  crutches.  Union,  if  it  takes  place,  is  usually 
cartilaginous,  but  is  sometimes  bony,  and  there  are  bound 
to  be  some  shortening  and  some  stiffness  of  the  joint.  Pas- 
sive motion  is  not  made  until  after  eight  weeks  have  elapsed. 
Senn  claims  that  by  his  method  of  "  immediate  reduction 
and  permanent  fixation  "  bony  union  is  obtained  in  fractures 


388 


MODERN  SURGERY. 


of  the  neck  of  the  femur  within  the  capsule.  He  "  places 
the  patient  in  the  erect  position,  causing  him  to  stand  with  his 
sound  leg  upon  a  stool  or  a  box  about  two  feet  in  height ; 
in  this  position  he  is  supported  by  a  person  on  each  side 
until  the  dressing  has  been  applied  and  the  plaster  has  set. 

"  Another  person  takes  care  of  the  fractured  limb,  which 
in  impacted  fractures  is  gently  supported  and  immovably 
held  until  permanent  fixation  has  been  secured  by  the  dress- 
ing. In  non-impacted  fractures  the  weight  of  the  fractured 
limb  makes  auto-extension,  which  is  often  quite  sufficient 
to  restore  the  normal  length  of  the  limb ;  if  this  is  not  the 
case,  the  person  who  has  charge  of  the  limb  makes  traction 
until  all  shortening  has  been  overcome  as  far  as  possible,  at 
the  same  time  holding  the  limb  in  position,  so  that  the  great 
toe  is  on  a  straight  line  with  the  inner  margin  of  the  patella 
and  the  anterior  superior  spinous  process  of  the  ilium.     In 

applying  the  plaster-of-Paris 
bandage  over  the  seat  of 
fracture  a  fenestrum,  cor- 
responding in  size  to  the 
dimensions  of  the  compress 
with  which  the  lateral  press- 
ure is  to  be  made,  is  left 
open  over  the  great  tro- 
chanter. 

"  To  secure  perfect  im- 
mobility at  the  seat  of 
fractures,  it  is  not  only 
necessary  to  include  in  the 
dressing  the  fractured  limb 
and  the  entire  pelvis,  but  it" 
is  absolutely  necessary  to 
also  include  the  opposite 
limb  as  far  as  the  knee  and 
to  extend  the  dressing  as  far  as  the  cartilage  of  the 
eighth  rib. 

"  The  splint  (Fig.  87)  is  incorporated  in  the  plaster-of-Paris 
dressing,  and  it  must  carefully  be  applied,  so  that  the  com- 
press, composed  of  a  well-cushioned  pad  with  a  stiff,  unyield- 
ing back,  rests  directly  upon  the  trochanter  major,  and  the 
pressure,  which  is  made  by  a  set-screw,  is  directed  in  the 
axis  of  the  femoral  neck.  Lateral  pressure  is  not  applied 
until  the  plaster  has  completely  set.  Syncope  should  be 
guarded  against  by  the  administration  of  stimulants. 

"  As  soon  as  the  plaster  has  sufficiently  hardened  to  retain 


Fig.   87. — Senn's 
apparatus. 


Fig.   88. — Senn's  appa- 
ratus applied. 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.     389 

the  limb  in  proper  position,  the  patient  should  be  laid  upon 
a  smooth,  even  mattress,  without  pillows  under  the  head, 
and  in  non-impacted  fractures  the  foot  is  held  in  a  straight 
position  and  extension  is  kept  up  until  lateral  pressure  can 
be  applied. 

"  No  matter  how  snugly  a  plaster-of- Paris  dressing  is 
applied,  as  the  result  of  shrinkage  it  becomes  loose,  and 
without  some  means  of  making  lateral  pressure  it  would 
become  necessary  to  change  it  from  time  to  time  in  order 
to  render  it  efficient.  But  by  incorporating  a  splint  in  the 
plaster  dressing  (Fig.  88)  this  is  obviated,  and  the  lateral 
pressure  is  regulated,  day  by  day,  by  moving  the  screw,  the 
proximal  end  of  which  rests  on  an  oval  depression  in  the 
center  of  the  pad." 

Extracapsular  Fracture  (fracture  of  the  base  of  the 
neck). — The  line  of  extracapsular  fracture  is  at  the  junction 
of  the  neck  with  the  great  trochanter,  and  is  partly  within 
and  partly  without  the  capsule,  the  fracture  being  generally 
comminuted  and  often  impacted.  The  cause  is  violent  direct 
force  over  the  great  trochanter  (as  by  falling  upon  the  side 
of  the  hip).  This  fracture  is  most  usual  in  elderly  people, 
but  is  not  very  uncommon  in  young  adults.  Stokes  has 
described  six  forms  of  extracapsular  fracture :  extracapsu- 
lar fracture  with  partial  impaction  posterior ;  fracture  with 
complete  impaction ;  fracture  with  partial  impaction  above ; 
fracture  with  partial  impaction  below,  the  shaft  being  split ; 
splitting  of  the  neck  longitudinally  without  impaction  ;  com- 
minuted non-impacted  fracture.^ 

SyjnptojHS. — When  impaction  is  absent  there  is  marked 
crepitus,  which  is  manifested  most  when  the  fingers  are  put 
over  the  great  trochanter;  there  is  great  pain,  pressure  upon 
the  great  trochanter  is  very  painful,  swelling  and  ecchy- 
mosis  are  marked ;  there  is  absolute  inability  on  the  part  of 
the  patient  to  move  the  limb,  and  passive  movements  cause 
great  pain ;  there  is  shortening  to  the  extent  of  at  least  one 
and  a  half  inches,  and  sometimes  three  inches,  which  short- 
ening is  made  manifest  by  noting  the  ascent  of  the  trochan- 
ter above  Nelaton's  line,  by  comparison  of  the  injured  limb 
with  the  sound  limb,  and  by  measuring  the  base-line  of 
Bryant's  triangle  on  each  side.  Absolute  eversion  exists 
with  slight  flexion  both  of  the  leg  and  the  thigh.  In  some 
rare  cases  inversion  exists.  This  happens  if  at  the  time  of 
the  accident  the  limb  was  inverted  and  adducted  (Stokes). 
Lagoria's  sign  and  Allis's  sign  are  present  (p.  384).    All  these 

'  Brit.  Med.  Jour.,  Oct.  12,  1895. 


390  MODERN  SURGERY. 

symptoms  follow  violent  direct  lateral  force.  In  the  im- 
pacted form  of  extracapsular  fracture,  in  addition  to  the 
aid  given  the  surgeon  by  the  history,  there  is  severe  pain 
which  is  intensified  by  movement  or  pressure ;  shorten- 
ing exists  to  the  extent  of  one  inch  at  least,  which  is  not 
corrected  by  extension ;  there  is  also  great  loss  of  function  ; 
and  whereas  the  limb  may  be  straight  or  even  inverted, 
it  is  usually  everted.  Crepitus  can  be  easily  obtained  when, 
there  is  no  impaction,  the  trochanter  moves  in  a  large 
arc  of  rotation  and  is  above  Nelaton's  line,  the  base-line 
of  Bryant's  triangle  is  shortened,  and  AlHs's  sign  is 
noted. 

Treatment. — In  treating  extracapsular  fracture  make  ex- 
tension, raise  the  foot  of  the  bed,  and  apply  the  extension 
apparatus  with  sand-bags  for  four  weeks ;  then  apply  a 
plaster  dressing  and  get  the  patient  up  on  crutches.  Remove 
the  plaster  at  the  end  of  four  weeks.  In  impacted  extra- 
capsular fracture  it  is  best  to  pull  apart  the  impaction  if  the 
patient  is  in  good  physical  condition.  Southam  of  Manches- 
ter, in  an  impressive  article,  has  recently  insisted  on  the 
absolute  necessity  of  pulling  apart  an  impaction.  He  gives 
ether,  and  when  the  patient  is  anesthetized  unlocks  the 
fragments.^ 

Fracture  of  the  Great  Trochanter. — This  process  may 
be  (i)  broken  off  without  any  other  injury,  but  in  most  cases 
(2)  the  line  of  fracture  runs  through  the  trochanter,  and 
leaves  one  portion  of  the  trochanter  attached  to  the  head 
and  neck  and  the  other  part  attached  to  the  shaft.  The 
cause  is  violent  direct  force  over  the  great  trochanter. 

Symptoms  and  Treatment. — The  symptoms  of  the  second 
form  are  similar  to  those  of  extracapsular  fracture.  On 
rotating  the  femur  the  lower  part  of  the  trochanter  moves 
with  it,  but  not  the  upper.  The  lower  fragment  goes  upward 
and  backward  and  projects  by  the  side  of  the  sciatic  notch. 
There  are  shortening,  eversion,  crepitus,  and  altered  position 
of  the  trochanter.  The  symptoms  of  the  first  form  resemble 
those  of  epiphyseal  separation.  The  treatment  of  the  second 
form  is  like  that  in  extracapsular  fracture,  and  the  first 
form  is  treated  like  separation  of  the  epiphysis  of  the 
trochanter. 

Separation  of  the  upper  epiphysis  of  the  femoral  head 
is  a  very  rare  result  of  accident ;  it  occurs  most  often  from 
disease  and  in  youth. 

Symptoms  and  Treatment. — The  symptoms  are  like  those 

1  Lancet,  Dec.  21,  1895. 


DISEASES  AXD   LXJURIES   OF  BONES  AND  JOINTS.    39 1 

of  fracture  of  the  neck,  except  that  the  crepitus  is  soft. 
The  trcatDioit  is  extension  as  above  directed. 

Separation  of  the  epiphysis  of  the  great  trochanter  is 
a  very  rare  accident.  The  cause  is  direct  violence,  and  the 
injury  occurs  only  in  youth. 

Symptoms. — The  trochanter  is  found  to  have  ascended 
and  passed  posteriorly ;  there  is  no  shortening ;  all  the 
motions  of  the  hip-joint  can  be  obtained ;  if  the  thigh  is 
flexed,  abducted,  and  rotated  externally,  and  the  fragment 
pushed  down  and  forward,  crepitus  is  obtained — soft  in 
epiphyseal  separation,  hard  in  fracture. 

Trcatmoit. — In  treating  separation  of  the  epiphysis  of  the 
great  trochanter  flex  the  leg  on  the  thigh  and  the  thigh  on 
the  pelvis,  place  the  extremity  upon  its  outer  surface,  keep  it 
fixed  by  some  form  of  retentive  apparatus,  and  try  to  draw 
the  trochanter  downward  and  forward  by  adhesive  strips  or 
by  a  pad  and  bandage.  Some  degree  of  lameness  is  inevi- 
table, even  after  Bryant's  extension.  Bryant's  extension 
directly  upward  may  admit  of  the  trochanter  being  pulled 
downward  upon  the  bone  (Fig.  93).  Extension  must  be 
applied  for  six  weeks,  and  crutches  and  pasteboard  splints 
are  used  for  four  weeks  more. 

2.  Fractures  of  the  shaft  of  the  femur  may  affect  any 
portion  of  the  shaft,  but  especially  the  middle  third,  and  may 
occur  at  any  age.  The  cause  of  fractures  in  the  upper  third 
is  usually  indirect  force ;  fractures  in  the  lower  third  are  due 
to  direct  force  ;  and  in  fractures  of  the  middle  third  these  tw^o 
causes  are  about  equally  potential.  Fracture  from  muscular 
action  occasionally  occurs.  Oblique  fracture  is  the  usual 
variety. 

Symptoms. — The  chief  symptom  in  fracture  of  the  shaft 
of  the  femur  is  great  displacement,  except  when  impaction 
occurs  or  when  the  break  is  in  a  child  and  the  periosteum  is 
untorn.  As  a  rule,  the  lower  fragment  is  drawn  up  and  is 
posterior  and  somewhat  to  the  inside  of  the  upper  fragment, 
and  undergoes  external  rotation  (the  drawing  up  is  due  to 
the  rectus  and  hamstrings ;  the  passing  inward  is  due  to  the 
adductor  muscles ;  the  rotation  outward  arises  from  the 
weight  of  the  limb).  In  fracture  of  the  upper  third  the 
upper  fragment  is  apt  to  be  thrown  strongly  forward  and 
outward.  Some  attribute  this  to  the  action  of  the  psoas, 
iliacus,  and  external  rotator  muscles,  but  Allis  thinks  it 
is  due  to  the  lower  fragment  pushing  the  upper  fragment 
into  this  position.  There  is  complete  loss  of  function,  the 
thicrh  and  lee  beine   semiflexed   and   everted.     There    are 


392 


MODERN  SURGERY. 


shortening  to  the  extent  of  two  or  three  inches,  pain  on 
movement,   preternatural    mobility,    crepitus,    and    obvious 


Fig.  89. — Dressing  of  fracture  of  the  femur  in  the  upper  third  with  extension  upon  a  double 
inclined  plane  (Agnew). 

deformity,  and  the  ends  of  the  fragments  can  be  felt.  In 
impaction  there  is  shortening  with  altered  axis  of  the  limb. 
Treatinent. — In  fractures  of  the  shaft  of  the  femur  some 
amount  of  permanent  shortening  is  almost  inevitable.  In  fract- 
ures of  the  upper  third  use  Agnew's  plan — namely,  a  double 
inclined  plane  with  extension  in  the  axis  of  the  partly-flexed 
thigh  (Fig.  89).     If,  notwithstanding  position  and  extension, 

the  upper  fragment  pro- 
jects, push  it  into  place 
and  bind  short  splints 
upon  the  limb.  Extension 
is  continued  for  four  weeks, 
a  plaster-of-Paris  bandage 
being  used  for  four  weeks 
more,  the  patient  being 
then  allowed  to  get  about 
on  crutches.  Some  sur- 
geons, in  fractures  of  the 
upper  third,  apply  a  plas- 
ter-of-Paris bandage  to  the 
leg,  thigh,  and  pelvis,  ex- 
tension being  made  from 
the  foot  while  the  dressing 
is  being  applied.  The 
anterior  splint  of  Nathan  R.  Smith  is  much  used  in  the 
South  in  treating  fractures  of  the  shaft  and  the  upper  ex- 
tremity (Fig.  90).  In  some  fractures  of  the  upper  third  no 
apparatus  will  maintain  reduction.  In  such  cases  it  is  ad- 
visable to  incise,  separate  the  muscle  from  between  the  ends 
of  the  bone,  and  fasten  the  ends  together  with  bone  ferrules. 


Fig.  go. — Smith's  anterior  splint. 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.    393 


silver  wire,  kangaroo-tendon,  steel  screws,  or  steel  pins.     In 
fractures  of  the  middle  third  and  upper  part  of  the   lower 


Fig.  91. — Hodgen's  suspending  apparatus. 

third  of  the  shaft,  use  the  extension  apparatus  (PI.  5,  Fig.  14) 
with  the  sand-bags,  carrying  the  plaster  to  just  below  the 
seat  of  the  fracture,  and  the  roller  bandage 
to  a  little  above  this  point.  Extension  is  to 
be  continued  for  four  weeks,  and  the  plaster- 
of-Paris  bandage  is  used  for  four  weeks  more. 
Many  surgeons  use  Hodgen's  splint  in  the 


Fig.  92. — Mclntyre's  splint 


treatment  of  fractures  of  the  thigh.     The  limb  is  suspended 
in  a  cradle  and  extension   is   obtained  by  strapping  the  foot 


394 


MODERN  SURGERY. 


to  the  cross-bar  of  the  frame  and  pulling  upon  the  frame 
by  cords  (Fig.  91).  In  fractures  of  the  lower  part  of  the 
lower  third  of  the  shaft  use  a  double  inclined  plane  (PI.  5,. 
Fig.  2)  alone.  A  Mclntyre  splint  (Fig.  92)  is  a  useful  form 
of  double  inclined  plane.  At  the  end  of  four  weeks  apply 
plaster,  which  is  to  be  worn  for  four  weeks.  In  children 
under  three  years  of  age  the  extension  apparatus  will  not 
satisfactorily  immobilize  the  fragments.  Fractures  of  the 
thigh  in  children  are  reduced  by  extension  and  counter- 
extension  ;  a  well-padded  splint  reaching  from  the  axilla  to 
below  the  sole  of  the  foot  is  applied  to  the  outer  side  of  the 
limb  and  body.  This  splint  is  held  in  place  by  bandages 
which  are  overlaid  with  plaster  of 
Paris.  It  is  worn  for  four  weeks,  at 
which  time  it  is  removed  and  a  plas- 
ter bandage,  applied  so  as  to  include 
the  entire  limb,  is  worn  for  four  weeks 
more. 

Bryant's  extension  is  very  satisfac- 
tory in  treating  a  child  (Fig.  93). 
Both  the  injured  limb  and  the  sound 
limb  should  be  flexed  to  a  right  angle 
with  the  pelvis,  fixed  by  light  splints, 
and  fastened  to  a  bar  above  the  bed. 
The  weight  of  the  body  produces 
counter-extension  and  the  child  can 
be  easily  cleaned  (Bryant's  Practice 
of  Siirgery). 

Fracture  just  above  the  Con- 
dyles.— The  line  of  this  fracture  is 
well  above  the  epiphyseal  line.  The 
femoral  artery  is  in  danger  from  the  fragments.  The  cause, 
as  a  rule,  is  direct  violence.  Indirect  force  is  sometimes 
responsible  (falls  upon  the  feet).  The  knee-joint  may  be 
opened.     The  fracture  is  sometimes  compound. 

Symptoms. — The  upper  end  of  the  lower  fragment  is  drawn 
upward  and  backward,  because  of  the  action  of  the  rectus, 
hamstrings,  gastrocnemius,  and  popliteus.  The  upper  frag- 
ment passes  inward,  and  the  deformity  is  very  manifest. 
There  are  shortening,  crepitus,  and  mobility.  The  ends  of 
the  fragments  can  be  felt.  If  the  force  has  been  very  great, 
a  T-fracture  results,  and  in  this  the  knee  is  broadened  and 
crepitus  is  got  by  moving  the  condyles,  one  up  and  the 
other  down. 

Treatment. — In  treating  fracture  at  the  base  of  the  condyles, 


Fjg.  93. — Bryant's  extension 
for  fracture  of  the  thigh  in  a 
child. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    395 

place  the  limb  on  a  double  inclined  plane  for  five  weeks, 
then  begin  passive  motion  once  every  other  day,  restoring 
the  limb  to  the  splint  after  the  movements  are  completed. 
At  the  end  of  eight  weeks  after  the  accident  remove  the 
dressings,  and,  if  the  knee-joint  be  stiff,  use  for  some  time 
massage,  motions,  hot  and  cold  douches,  ichthyol  inunctions, 
etc.  Bryant  treats  this  fracture  in  extension,  cutting  the 
tendo  Achillis,  if  necessary,  to  amend  deformity.  It  is  occa- 
sionally necessary  to  wire  the  fragments.  Some  cases  de- 
mand amputation  because  of  injury  to  the  structures  in  the 
popliteal  space. 

Fracture  Separating-  Either  Condyle. — The  cause  of  this 
fracture  is  direct  force. 

SynnptoDis  and  Treatment. — The  broken  piece  is  drawn 
upward,  the  leg  bends  toward  the  injury,  crepitus  exists,  the 
knee  is  much  broadened,  there  is  no  shortening,  and  con- 
siderable swelling  is  sure  to  arise.  In  treating  a  fracture 
separating  either  condyle,  use  a  double  inclined  plane  as 
directed  above. 

Longitudinal  fractures  run  up  from  the  knee-joint.  The 
cause  is  a  fall  upon  the  feet  or  the  knees. 

Symptoms  and  Treatment. — The  symptoms  of  longitudinal 
fracture  are  often  obscure.  The  femur  is  broadened  when 
the  knee  is  flexed.  The  split  is  detected  between  the  con- 
dyles. The  treatment  is  the  straight  position  in  plaster  for 
eight  weeks. 

Separation  of  the  lower  epiphysis  occurs  only  before 
the  twenty-first  year. 

Symptoms. — The  symptoms  in  separation  of  the  lower 
epiphysis  are  like  those  of  fracture,  but  crepitus  is  moist. 
The  danger  is  that  the  growth  of  bone  will  be  stunted. 

Treatment. — The  treatment  for  separation  of  the  lower 
epiphysis  is  a  double  inclined  plane  as  above  directed. 

Fracture  of  the  patella  is  a  very  common  accident.  The 
ca?tse  is  direct  force  (producing  vertical,  star-shaped,  or 
oblique  lines  of  fracture)  or  muscular  action  (producing  a 
transverse  line  of  fracture). 

Fractures  of  the  Patella  by  Muscular  Action. — The 
knee-cap  is  more  often  broken  by  muscular  action  than  is 
any  other  bone.  When  the  knee  is  partly  flexed  the  middle 
third  of  the  patella  rests  upon  the  condyles  of  the  femur  and 
the  upper  third  of  the  knee-cap  projects  above  them ;  when 
in  this  position  a  contraction  of  the  quadriceps  may  easily 
cause  a  fracture  near  the  center  of  the  bone  (Fig.  94).  Both 
patellae  may  be  broken  at  once.     In  this  form  of  fracture  the 


396  MODERN  SURGERY. 

joint,  and  often  the  prepatellar  bursa,  is  opened.     Fractures 
by  muscular  action  are  transverse. 

Symptoms. — The  symptoms  in  fractures  by  muscular  action 

are — rapid  and  enormous  swelling,  due  to  the  effusion  first 

of  blood  and  then  of  synovia  and  inflammatory  products  into 

and  around  the  joint ;  absolute  inability 

^^^  p.         to  raise  the  limb  from  the  bed.     The  frag- 

"^         Y  I        ments  are  widely  separated,  this  separa- 

':>i«^.Wx^^^,.//\  I        tion  being  distinctly  manifest  to  the  touch 

''^- —    J        unless  swelling  is  great.     The  separation 

1  I         is  accentuated    by   flexion    of    the   leg. 

\--'iWv\  Crepitus  is  detected    if  the  upper  frag- 

l^^J  ment  can  be  pushed  down  until  it  touches 

Fig.  94.— Mechanism  of     the  lowcr  piccc,  but  if  swcUing  is  great 

^scukrfct^n  fxreves)'.^     this  cannot  be  done.     Union,  if  it  occurs, 

will  probably  be  ligamentous,  and  if  the 

patient  gets  about  too  soon,  apparently  well-united  fragments 

will  by  degrees  stretch  far  asunder. 

Transverse  Fractures  of  the  Patella. —  Treatment. — If  the 
swelling  in  transverse  fracture  of  the  patella  be  so  great  as 
to  prevent  approximation  of  the  fragments,  reduce  it  by 
bandaging  for  a  day  or  two,  by  using  ice-bags  and  lead- 
water  and  laudanum,  or  by  aspirating  the  joint.  When  the 
swelling  diminishes,  bring  the  two  fragments  into  apposition, 
pull  them  together  by  adhesive  plaster,  and  put  on  a  well- 
padded  posterior  splint.  Run  a  piece  of  adhesive  plaster 
over  the  upper  end  of  the  upper  fragment,  draw  the  bone 
down  and  fasten  the  plaster  behind  and  below  the  joint. 
Run  another  piece  of  plaster  over  the  lower  end  of  the 
lower  fragment,  draw  the  bone  up,  and  fasten  the  plaster 
behind  and  above  the  joint.  A  third  piece  is  run  over  the 
junction  of  the  fragments  to  prevent  tilting.  Agnew's  splint 
admirably  accomplishes  this  approximation  (PI.  5,  Figs.  11, 
12).  A  bandage  holds  the  splint  in  place,  and  maybe  carried 
around  the  knee  by  figure-of-8  turns.  The  heel  is  sometimes 
raised  upon  a  pillow  so  as  to  extend  the  leg  and  to  semiflex 
the  thigh,  but  this  is  not  essential.  Remove  and  reapply 
the  dressing  every  few  days,  as  it  inevitably  becomes  loose. 
At  the  end  of  three  weeks  remove  the  splint  permanently 
and  apply  a  plaster-of- Paris  dressing  from  just  above  the 
ankle  to  the  middle  of  the  thigh.  The  dressing  is  to  be  worn 
for  five  weeks.  At  the  end  of  eight  weeks  let  the  patient 
walk  with  canes,  the  joint  being  kept  fixed  for  four  weeks 
more  by  pasteboard  splints  or  by  a  light  plaster-of-Paris 
bandage.     For   one   year   after    removing   the    splints   and 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.     397 


plaster  a  lacing  knee-cap  and  a  posterior  splint  should  be 
worn  to  support  the  joint.  The  plan  of  prolonged  retention 
renders  more  or  less  joint-stiffness  a  certain  occurrence,  but 
this  is  less  of  an  impediment  than  the  wide  separation  of  the 
fragments  that  inevitably  attends  an  early  use  of  the  joint. 
W.  Barton  Hopkins,  of  the  Pennsylvania  Hospital,  has 
devised  an  excellent  adhesive-plaster  dressing,  by  means  of 
which  extension  is  maintained  upon  the  upper  fragment. 
Bryant  of  New  York  has  devised  an  ambulatory  dressing. 

Malgaigne's  hooks  (Fig.  95),  if  employed  to  treat  these 
fractures,  are  to  be  inserted  with  the  full  antiseptic  care  of 
an  ordinary  surgical  opera- 
tion. Insert  the  lower  hooks 
just  below  the  point  of  the 
patella,  entering  them  under 
its  edge,  press  the  fragments 
together,  draw  up  the  skin 
over  the  upper  fragment  to 
prevent  puckering,  and  insert 
the  upper  hooks  with  force 
just  above  the  upper  fragment,  letting  the  points  of  the 
hooks  bear  upon  the  bone.  Lock  or  screw  the  hooks  to- 
gether, dress  with  antiseptic  gauze,  and  apply  a  posterior 
sphnt  Remove  the  hooks  in  three  weeks,  and  treat  with 
plaster  as  in  the  preceding  case  when  the  special  splint  was 
removed. 

Among  other  plans  of  treatment  may  be  mentioned  wiring 
the  fragments  (see  Operations  upon  Bones) ;  encircling  the 
fragments  with  a  subcutaneous  silk  ligature ;  passing  a  pin 


Fig.  95.  — Malgaigne's  hooks. 


Fig.  96. — Needle  specially  designed  to  carry  a  thick  wire.  The  eye  is  drilled  obliquely, 
and  should  receive  only  a  little  loop  on  the  end  of  the  wire ;  this  little  loop  should  be  made 
previously  {vide  Figs.  97,  98,  Barker). 


through  the  tendon  of  the  quadriceps,  another  through  the 
ligament  of  the  patella,  and  approximating  the  two  by  figure- 
of-8  turns  with  a  silk  cord,  thus  drawing  together  the  frag- 
ments. Barker  believes  strongly  in  wiring  recent  transverse 
fractures.  He  does  it  with  antiseptic  care  soon  after  the 
accident,  and    permits  passive  motion  or  even  slight  active 


398 


MODERN  SURGERY. 


motion  immediately  after  the  operation.  Massage  is  begun 
the  day  after  the  operation  and  is  continued  for  two  weeks. 
Barker  ^  uses  a  special  needle  (Fig.  96)  and  silver  wire  of 
the  thickness  of  a  No.  i  English  catheter.  This  wire  is 
straightened  and  softened  in  a  spirit-flame.  He  rubs  the 
fragments  together  in  order  to  dislodge  blood  or  fibrous 
material,  and  when  marked  grating  occurs  he  introduces  the 
wire.  A  puncture  with  a  small  knife  is  made  through  the 
middle  of  the  upper  attachment  of  the  patellar  ligament. 


Fig.  97. — Needle  (a)  introduced  behind  the  fragments,  and  receiving  one  end  {U)  of  the 
silver  wire  (b,  c)  (Barker). 

The  needle,  not  carrying  any  wire,  is  made  to  enter  through 
this  opening  into  the  joint,  is  passed  back  of  the  fragments, 
pierces  the  tendon  of  the  quadriceps  at  the  upper  edge  of 
the  upper  fragment,  and  its  point  is  cut  upon  with  a  knife. 
The  wire  is  inserted  into  the  eye  of  the  needle  and  the  needle 
is  withdrawn  and  unthreaded.  The  empty  needle  is  pushed 
through  the  lower  opening,  is  carried  in  front  of  the  joint,  is 
made  to  emerge  at  the  upper  opening,  is  threaded  again  and 
withdrawn  (Figs.  97,  98).  The  wires  are  threaded  into  bars 
and  twisted  (Fig.  99). 

Fractures  of  the  patella  by  direct  force   are  vertical, 
stellate,  oblique,  or  V-shaped,  and  are  often  incomplete. 

1  Brit.  Med.  Jour.,  April  ii,  1896. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    399 


Symptoms.  —  Fractures 
of  the  patella  by  direct 
force  are  indicated  by  dis- 
coloration, swelling,  great 
difficulty  in  movement,  and 
much  pain.  There  may  or 
may  not  be  crepitus,  and 
rarely  is  there  separation 
of  the  fragments.  Bony 
union  occurs  in  these 
fractures. 

Treatment. — F  r  a  c  t  u  r  e 
by  direct  force  requires  a 
posterior  splint,  the  local 
use  of  lead-water  and 
laudanum,  and  the  appli- 
cation of  a  bandage.  If 
there  is  any  separation, 
approximate  the  frag- 
ments by  bandages  and 
compresses.  The  dan- 
ger in  these  cases  is  not  non-union,  but  ankylosis ;  hence, 


Fig.  98. — Needle  [a)  passed  in  front  of  the 
fragments  and  receiving  the  other  end  (c)  of  the 
silver  wire  (b,  c)  (Barker). 


Fig.  99. — Wire  in  position  round  fragments  and  threaded  through  metal  bars.     The  lower 
and  posterior  wire  runs  upward  to  the  left  of  the  upper,  ready  for  twisting  (Barker). 


begin  passive  motion  of  the  knee-joint  in  the  fourth  week 


400  MODERN  SURGERY. 

after  the  accident.  Remove  the  dressings  at  the  end  of  six 
weeks,  and  let  the  patient  at  once  get  about. 

Fractures  of  the  Leg. — In  leg-fcactures  both  bones  or 
only  one  bone  may  be  broken. 

Fractures  of  the  tibia  are  divided  into  (i)  fractures  of  the 
upper  end ;  (2)  separation  of  the  upper  epiphysis ;  (3)  fract- 
ures of  the  shaft ;  (4)  fractures  of  the  lower  end ;  and  (5) 
separation  of  the  lower  epiphysis. 

Fractures  of  the  upper  end  of  the  tibia  are  uncommon. 
They  may  be  transverse,  oblique,  or  vertical,  running  into  the 
joint.     The  cause  is  direct  violence. 

Symptoms. — In  fracture  of  the  upper  end  of  the  tibia  there 
is  contusion  of  the  soft  parts.  In  a  transverse  fracture  there 
are  mobility  and  crepitus,  but  there  is  little  displacement.  In 
oblique  fracture  crepitus  and  mobility  are  marked  and  the  axis 
of  the  limb  is  altered.  In  vertical  fractures  entering  the  joint 
there  is  great  swelling  of  the  knee-joint.  In  comminuted 
fractures,  which  exhibit  marked  signs,  union  is  readily  ob- 
tained, but  if  the  joint  has  been  damaged  stiffness  is  sure  to 
ensue. 

Treatmeytt. — In  treating  fractures  of  the  upper  end  of  the 
tibia  employ  a  double  inclined  plane  in  the  form  of  a  Mcln- 
tyre  splint  (Fig.  92)  or  in  the  form  of  a  fracture-box  (PI.  5, 
Fig.  i).  Lead- water  and  laudanum  are  applied  about  the 
knee-joint.  At  the  end  of  the  fourth  week  begin  passive 
motion,  reapplying  the  splint  after  each  daily  seance.  In  six 
weeks  let  the  patient  get  about,  first  with  crutches,  then  with 
a  cane,  then  without  any  artificial  support. 

Separation  of  the  Upper  Epiphysis  of  the  Tibia. — There 
is  only  one  recorded  case  (Pick). 

Fractures  of  the  Shaft  of  the  Tibia. — The  cause  of  these 
fractures  is  direct  force.  The  fracture  is  generally  transverse 
in  the  upper  part  of  the  bone  and  oblique  in  the  lower  part 
(Pickering  Pick). 

Symptoms. — In  transverse  fracture  of  the  shaft  of  the  tibia 
there  is  no  deformity,  and  the  support  of  the  fibula  may  even 
permit  of  walking ;  there  is  fixed  pain  ;  there  may  or  may 
not  be  inequality  of  fragments  felt  by  the  finger ;  and  there 
are  crepitus,  mobility,  and  often  linear  ecchymosis.  In  oblique 
fractures  there  usually  exist  crepitus,  a  little  mobility,  and 
some  deformity.  The  deformity  depends  on  the  direction 
of  the  line  of  fracture,  and,  as  this  line  is  usually  from  above 
downward,  inward,  and  a  little  forward,  the  lower  fragment 
usually  passes  behind  the  upper  fragment  and  rotates  inward. 

Treatment. — In  treating  fractures  of  the  shaft  of  the  tibia, 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    4OI 

if  there  be  much  swelHng,  put  the  Hmb  in  a  fracture-box 
(PI.  5,  Fig.  I  ;  Fig.  100)  and  apply  lead-water  and  laudanum. 
A  silicate-of-sodium  or  a  plastcr-of-Paris  dressing  is  applied 
when  the  swelling  subsides,  or  the  dressing  is  used  at  once 


Fig.  100. — Fracture-box  in  fractures  of  the  bones  of  the  leg. 


if  swelling  is  slight.  The  patient  gets  about  on  crutches. 
The  dressing  is  removed  in  six  weeks,  and  the  patient  goes 
about  for  one  week  on  crutches,  lightly  using  the  foot,  and 
then  for  one  week  with  a  cane.  At  the  end  of  eight  weeks 
the  leg  may  be  used,  but  not  too  much  at  first. 

Fractures  of  the  Lo^wer  End  of  the  Tibia :  Fracture 
of  the  Inner  Malleolus. — The  cause  of  fracture  of  the  inner 
malleolus  is  direct  force. 

Symptoms  and  Treatment. — The  symptoms  of  fracture  of 
the  inner  malleolus  are  some  downward  displacement,  de- 
pression above  the  fragment,  mobility,  and  crepitus.  The 
treatment  is  to  push  the  fragment  into  place  and  use  side- 
splints  or  a  fracture-box  for  two  weeks,  when  a  plaster-of- 
Paris  or  a  silicate  dressing  may  be  substituted  and  the  pa- 
tient be  ordered  to  use  crutches.  Remove  the  plaster  four 
weeks  after  it  is  applied,  and  direct  the  patient  to  gradually 
bear  his  weight  upon  the  leg,  as  outlined  above. 

Separation  of  the  lo"wer  epiphysis  of  the  tibia  is  a  very 
rare  accident.  The  treatment  is  a  fixed  dressing  for  six 
weeks. 

Fracture  of  the  fibula  alone  is  commoner  by  far  than  is 
fracture  of  the  tibia  alone.  Fractures  in  the  upper  two-thirds, 
which  are  rare,  are  usually  due  to  direct  force.  Fractures  in 
the  lower  third  are  frequent,  and  they  arise  from  indirect 
force. 

26 


402  MODERN  SURGERY. 

Fractures  of  the  Upper  Two-thirds  of  the  Fibula. — In 

these  fractures  the  cause  is  direct  force. 

Syinpto7ns. — In  fracture  of  the  upper  two-thirds  of  the 
fibula  the  patient  can  often  walk.  The  bone  is  deeply  situ- 
ated, and  displacement  cannot  often  be  made  out.  There  is 
a  fixed  pain,  which  is  intensified  by  movement  and  by  press- 
ure. Pressure  upon  the  lower  fragment  does  not  move  the 
upper  fragment.  Crepitus  is  sometimes  felt,  and  a  linear 
ecchymosis  is  apt  to  appear.  The  bone  bends  normally, 
hence  slight  mobility  is  of  no  value  diagnostically. 

Treatment. — In  treating  a  fracture  of  the  upper  two-thirds 
of  the  fibula  apply  a  plaster-of-Paris  or  a  silicate  bandage 
and  direct  that  it  be  worn  for  six  weeks.  Weight  is  not  to 
be  put  upon  the  foot  for  six  weeks  after  the  accident. 

Fractures  of  the  Lower  Third  of  the  Fibula. — In  these 
fractures  the  cause  is  indirect  force,  especially  twists  of  the 
foot.  Forcible  inversion  of  the  foot  pulls  upon  the  external 
lateral  ligament  and  the  external  malleolus,  forces  the  fibula 
outward,  and  tends  to  break  it,  the  lower  fragment  being  dis- 
placed outward.  Forcible  eversion  pulls  the  internal  lateral 
ligament  off  from  the  inner  malleolus  (often  breaks  the  mal- 
leolus) and  fractures  the  fibula  above  the  ankle,  the  bone 
being  displaced  inward. 

Symptoms. — In  the  lower  third  of  the  fibula  the  bone  is 
superficial,  and  the  irregularity  of  a  fracture  is  manifest  to 
the  touch.  There  is  localized  pain,  which  is  increased  by 
pressure  or  by  motion.  Crepitus  may  exist.  Deformity  is 
often  exhibited  by  the  position  of  the  foot. 

Pott's  fracture,  which  is  a  fracture  of  the  lower  fifth  of 
the  fibula  accompanied  by  outward  dislocation  of  the  foot, 
is  due  to  powerful  eversion  of  the  foot.  This  outward 
dislocation  is  rendered  possible  by  rupture  of  the  deltoid 
ligament  or — what  is  far  commoner — by  the  tearing  off  of 
a  portion  of  the  internal  malleolus. 

Treatment. — In  fractures  of  the  lower  third  of  the  fibula, 
after  reducing  displacement,  place  the  limb  in  a  fracture-box 
containing  a  soft  pillow.  A  bird's-nest  pad  of  cotton  or 
oakum  is  made  for  the  heel  (Fig.  lOo).  A  fillet  around  the 
ankle  fastens  the  foot  to  the  foot-piece  of  the  box ;  a  pad 
of  oakum  rests  between  the  foot-piece  and  the  sole.  If 
dressing  Pott's  fracture,  put  a  compress  above  the  inner 
malleolus  and  another  compress  below  the  outer  malleolus. 
Close  the  sides  of  the  box  and  tie  them  together  with  a 
bandage.  Swing  the  box,  if  desired,  on  a  gallows.  Every 
day  let  down  the  sides  of  the  box  and  rub  the  leg,  the  ankle, 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    403 

and  the  foot  with  alcohol.  In  ten  days  apply  a  plaster-of- 
Paris  bandage  and  let  the  patient  get  about  on  crutches. 
Remove  the  plaster  at  the  end  of  the  fifth  week  after  the 
accident,  and  let  the  patient  go  about  with  crutches  for  one 
week  and  with  a  cane  for  a  week  longer. 

Some  surgeons  dress  Pott's  fracture  with  a  Dupuytren 
spHnt.  This  is  a  straight  splint  (PI.  5,  Fig.  9)  which  reaches 
from  the  head  of  the  tibia  to  or  below  the  toes.  This  splint 
is  padded,  and  a  pyramidal  pad  with  the  base  down  is  laid 
upon  the  inner  surface  of  the  leg,  above  the  inner  malleolus, 
the  splint  being  put  upon  the  inner  surface  of  the  leg,  over 
the  pad.  The  splint  is  fastened  as  shown  on  Plate  5  (Fig.  9), 
and  the  leg  is  semiflexed  upon  the  thigh  and  is  laid  upon  its 
outer  surface  on  a  pillow.  After  ten  days  apply  the  plaster- 
of-Paris  bandage,  which  is  to  be  worn  as  above  directed.  In 
Pott's  fracture  Biyant  advises  the  use  of  a  posterior  splint, 
two  lateral  splints,  and  a  swing. 

Fracture  of  both  bones  of  the  leg-,  a  very  common  in- 
jury, is  often  compound,  and  is  not  unusually  comminuted. 
Fractures  by  direct  force,  such  as  blows  or  kicks,  are  com- 
monest in  the  upper  half  of  the  leg.  Fractures  by  indirect 
force,  as  by  falls,  are  commonest  in  the  lower  half  of  the  leg. 
In  fractures  from  indirect  force  the  tibia  breaks  first,  and 
then  the  fibula  breaks  at  a  higher  level.  The  point  of 
greatest  liability  to  fracture  from  indirect  force  is  the  junc- 
tion of  the  low^er  and  middle  thirds.  Fractures  of  the  leg 
are  usually  oblique,  but  they  may  be  transverse  if  arising 
from  direct  force.  Spiral,  torsion,  or  V-shaped  fractures  and 
longitudinal  breaks  sometimes  occur.  In  oblique  fractures, 
as  a  rule,  the  line  of  fracture  runs  downward,  inward,  and  a 
little  forward. 

Symptoms. — Fracture  of  both  bones  of  the  leg  is  easy  of 
recognition.  The  fibular  fracture  is  detected  as  before  de- 
scribed. By  running  the  finger  along  the  crest  of  the  tibia 
displacement  will  be  found,  except  in  transverse  fractures, 
when  it  may  not  occur.  The  common  displacement  is  for 
the  lower  fragment  to  ascend  and  pass  behind  the  lower  end 
of  the  upper  fragment  and  to  rotate  a  little  outward,  and 
for  the  upper  fragment  to  project  in  front.  This  ascent  is 
due  to  the  action  of  the  gastrocnemius  and  soleus  muscles. 
If  the  line  of  fracture  is  in  a  direction  the  reverse  of  that 
which  is  usual,  the  lower  fragment  ascends  in  front  of  the 
lower  end  of  the  upper  fragment.  In  fracture  of  both  bones 
there  are  marked  mobility,  crepitus,  pain,  and  inability  to 
walk.     In  fractures  from  direct  force  there  is  more  or  less 


404  MODERN  SURGERY. 

damage  to  the  soft  parts.  A  fracture  near  the  ankle  is  dis- 
tinguished from  a  dislocation  by  the  fact  that  the  deformity 
is  easily  reduced,  but  tends  to  recur  in  the  fracture,  and, 
further,  that  in  a  fracture  the  relations  of  the  malleoli  to  the 
tarsus  are  unaltered. 

Treatment. — If  the  fracture  is  near  the  ankle-joint,  the 
action  of  the  tendo  Achillis  may  maintain  deformity,  and  in 
such  cases  the  tendon  must  be  divided.  In  treating  a  simple 
fracture  of  the  lower  two-thirds  of  the  bones  reduce  by  ex- 
tension and  counter-extension,  and  use  a  fracture-box  (PI.  5, 
Fig.  i)  as  in  Pott's  fracture  (p.  402),  though  the  compresses 
are  not  required.  If  the  soft  parts  are  bruised,  use  lead-water 
and  laudanum ;  if  they  are  abraded,  apply  antiseptic  dress- 
ings. The  fracture-box  may  be  swung  upon  a  gallows.  After 
three  weeks  apply  plaster-of-Paris  or  silicate-of-sodium  dress- 
ing and  let  the  patient  sit  up  in  a  chair  daily  for  one  week ; 
at  the  end  of  this  time  the  patient  may  get  about  with 
crutches.  At  the  end  of  six  weeks  after  the  accident  re- 
move the  plaster,  and  let  the  sufferer  get  about  with  crutches 
for  two  weeks  and  with  a  cane  for  two  weeks  more.  Brinton 
dresses  a  fracture  of  both  bones  of  the  leg  for  two  weeks 
in  a  fracture-box,  for  two  weeks  in  side-splints,  and  for  two 
weeks  in  an  immovable  dressing,  allowing  the  patient  to  get 
about  as  soon  as  the  plaster  is  put  on.  Instead  of  the  fract- 
ure-box, we  may  use  a  posterior  splint,  two  lateral  splints, 
and  a  swing.  Shrimpton  of  Paris  uses  Nathan  R.  Smith's 
anterior  splint  in  fracture  of  the  leg.  Many  surgeons  apply 
plaster-of-Paris  in  the  form  of  an  ambulatory  dressing.  In 
this  dressing  a  solid  apparatus  reaches  up  to  the  lower  third 
of  the  thigh  and  below  the  sole  of  the  foot.  When  the 
patient  walks  the  weight  is  transmitted  to  the  thigh.  In 
fractures  of  the  upper  third  of  the  leg  the  Mclntyre  splint 
or  the  double  inclined  plane  is  used.  If  the  fracture  is  com- 
pound, asepticize  thoroughly,  make  a  counter-opening,  insert 
a  drainage-tube,  dress  with  bichlorid  gauze,  apply  a  plaster 
bandage,  and  cut  trap-doors  over  the  openings  of  the  tube 
(see  Fig.  70).  Remove  the  tube,  as  a  rule,  in  about  forty- 
eight  hours ;  but  the  patient's  temperature  is  a  better  guide 
than  time. 

Fractures  of  the  bones  of  the  foot  are  rather  rare  acci- 
dents. Owing  to  the  number  of  the  bones  and  to  the 
elasticity  of  their  connections,  the  force  of  blows  and  falls 
is  spread  and  dissipated.  Fractures  from  direct  force  are 
often  compound.  The  cause  of  fracture  of  either  the  scaph- 
oid, the  cuboid,  or  any  of  the  cuneiform  bones  is   direct 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    405 

force.  Fractures  of  the  os  calcis  and  astragalus  arise,  as 
a  rule,  from  indirect  force,  such  as  falls,  but  the  calcaneum 
may  be  broken  by  direct  violence.  In  rare  instances  the 
OS  calcis  has  been  broken  by  contraction  of  the  great  calf- 
muscles. 

Symptoms. — In  fracture  of  the  os  calcis  there  are  severe 
pain,  swelling,  crepitus,  mobility,  often  an  apparent  widening 
of  the  bone,  not  unusually  a  loss  of  the  arch  of  the  foot 
(Pick).  In  some  cases  the  posterior  fragment  is  drawn  up 
by  the  calf-muscles,  and  in  other  cases  there  is  deformity. 
In  fracture  of  the  astragalus  displacement  may  occur  which 
resembles  that  of  a  dislocation.  Crepitus  may  or  may  not 
be  detected.  It  can  be  elicited,  as  a  rule,  by  rotating  the 
foot  while  the  heel  is  firmly  held.  If  crepitus  cannot  be 
found,  it  is  not  certain  that  a  fracture  is  present,  though  the 
patient  may  be  unable  to  stand  and  there  may  be  swelling 
and  pain  on  pressure.  Fractures  of  the  other  bones  are 
hard  to  detect.  There  may  or  may  not  be  crepitus,  which, 
if  it  exists,  is  hard  to  localize ;  there  is  pain  on  standing  and 
on  pressure,  and  there  is  bruising  of  the  soft  parts. 

Treatment. — To  treat  a  fracture  of  the  os  calcis  when  no 
deformity  exists,  use  a  fracture-box  for  two  weeks  ;  maintain 
the  foot  at  a  right  angle  to  the  leg ;  apply  lead-water  and 
laudanum ;  then  put  on  an  immovable  dressing,  and  let  it 
be  worn  for  four  weeks.  In  fracture  of  the  os  calcis  with 
drawing  up  of  the  posterior  fragment  flex  the  leg  upon  the 
thigh,  extend  the  foot,  and  maintain  this  position  by  means 
of  a  band  around  the  thigh,  the  band  being  fastened  by 
means  of  a  cord  to  a  slipper  (PI.  6,  Fig.  5),  the  leg  resting 
upon  its  outer  side.  At  the  end  of  two  weeks  apply  plaster, 
and  let  it  be  worn  for  four  weeks.  Many  cases  require 
incision  and  nailing  or  wiring  the  fragments  together.  If 
the  projecting  fragment  of  the  os  calcis  cannot  be  forced 
into  place,  and  if  it  makes  dangerous  pressure  upon  the 
skin,  excise  it ;  if  it  does  not  make  pressure  which  threatens 
sloughing,  place  the  joint  in  a  position  favorable  for  anky- 
losis, and  immobilize.  In  a  fracture  of  the  astragalus,  use  a 
fracture-box  and  then  an  immovable  dressing,  as  in  fracture 
of  the  OS  calcis  without  deformity.  Fractures  of  the  other 
bones  of  the  tarsus  are  almost  invariably  compound,  and  the 
injury  may  require  drainage  and  immovable  dressing,  excis- 
ion, or  even  amputation. 

Fractures  of  the  metatarsal  bones  are  due  to  direct 
force  and  are  almost  always  compound.  Fractures  from 
crushes    usually   demand    excision    or   amputation.     When 


406  MODERN  SURGERY. 

only  one  bone  is  broken  displacement  is  slight,  there  is 
severe  pain  on  motion  and  pressure,  and  crepitus  can  gener- 
ally be  obtained.  A  simple  fracture  of  a  metatarsal  bone 
is  dressed  in  an  immovable  dressing  for  four  vi'eeks. 

Fractures  of  the  phalanges  of  the  toes  are  due  to  direct 
force  and  are  often  compound.  They  may  require  imme- 
diate amputation. 

Treatment. — In  a  compound  fracture  where  amputation  is 
unnecessary,  drain  with  strands  of  catgut  for  forty-eight 
hours  and  dress  antiseptically ;  at  the  end  of  this  time  apply 
over  the  bichlorid  gauze  a  gutta-percha  or  a  pasteboard 
splint  extending  from  beyond  the  end  of  the  toe  to  well  up 
upon  the  sole  of  the  foot,  and  fix  the  splint  in  place  with  a 
spiral  bandage  of  the  toe  and  instep.  The  splint  is  to  be 
worn  for  four  weeks.  In  a  simple  fracture  fasten  the  injured 
toe  to  an  adjacent  toe  or  toes  by  a  plaster  bandage  to  be 
worn  for  three  weeks. 

3,  Diseases  of  the  Joints. 

Synovitis  is  a  primary  inflammation  of  the  synovial  mem- 
brane alone.  If  other  structures  besides  the  synovial  mem- 
brane are  involved,  the  condition  is  known  as  "  arthritis." 
Two  forms  of  simple  synovitis  exist — namely,  acute  and 
chronic.     Some  surgeons  speak  also  of  subacute  cases. 

Acute  Simple  Synovitis. — The  causes  of  acute  simple 
synovitis  are  contusions,  sprains,  twists,  and  overuse.  The 
causative  influence  of  exposure  to  cold  or  damp  has  been 
much  debated.  It  seems  probable  that  in  some  cases  cold 
produces  vasomotor  paresis  of  the  vessels  of  the  synovial 
membrane,  a  condition  which  may  eventuate  in  inflammation. 
The  membrane  is  red  and  swollen  and  the  joint  contains  an 
excess  of  turbid  fibrinous  fluid.  If  the  inflammation  ad- 
vances, arthritis  arises  and  sometimes  blood  is  effused. 

Symptoms. — The  symptoms  of  acute  synovitis  are — pain, 
which  is  increased  by  motion  of  the  joint,  by  pressure  upon 
the  articulation,  and  by  a  dependent  position  of  the  limb, 
and  which  is  worse  at  night.  Pressure  upon  the  cartilage 
does  not  cause  pain,  but  friction  of  the  synovial  membrane 
at  once  develops  it.  The  patient  places  the  limb  in  the 
position  which  gives  the  greatest  ease,  and  in  this  position 
the  part  becomes  more  or  less  fixed.  A  fluctuating  swelling 
is  noted,  most  marked  between  the  ligaments,  which  swell- 
ing bulges  out  the  synovial  area  and  hides  or  obscures  the 
articular  heads  of  the  bones.     The  swelling  is  due  early  to 


DISEASES  AXD   INJURIES   OF  BOXES  AND  JOIXTS.    407 

extensive  secretion  of  synovia,  and  later  to  effusion  of  liquor 
sanguinis.  Bulging  takes  place  at  points  where  the  capsule  is 
thin,  and  at  such  points  fluctuation  may  be  detected.  Fluc- 
tuation in  the  elbow  is  sought  for  posteriorly.  Fluctuation  in 
the  knee  is  sought  for  on  either  side  in  front.  A  large  effu- 
sion in  the  knee  floats  the  patella  up  from  the  condyles.  A 
small  effusion  in  the  knee  can  be  detected  by  Fiske's  plan  ; 
that  is,  cause  the  patient  to  bend  forward  at  the  hips,  resting 
each  hand  on  the  front  of  the  corresponding  thigh.  The 
anterior  structures  of  the  joint  are  relaxed,  and,  by  tapping 
the  patella,  even  a  small  effusion  can  be  discovered.  The 
skin  ov^er  the  joint  is  rarely  reddened,  but  feels  hot  to  the 
hand  of  the  observer  (over  more  superficial  joints,  but  not 
over  shoulder  and  hip) ;  the  joint  is  partly  flexed ;  fever 
exists,  var>nng  in  degree  with  the  size  of  the  joint,  the  acute- 
ness  of  the  attack,  and  the  nature  of  the  cause.  Suppura- 
tion rarely  follows  simple  synovitis,  but  if  it  does,  rigors 
occur,  there  is  a  septic  temperature,  and  the  joint  soon 
gives  evidence  of  containing  pus  (periarticular  edema). 
Traumatic  synovitis  without  infection  tends  toward  cure 
without  suppuration  if  the  patient  is  healthy,  and  after  it 
ankylosis  is  rare. 

Trcatmoit. — In  treating  acute  synovitis  immobilize  the 
joint.  In  sev^ere  cases  place  it  in  such  a  position  that  the 
limb  will  still  be  useful  even  if  ankylosis  occurs.  In  mild 
cases  we  can  immobilize  in  the  position  of  rest  (semiflexion), 
apply  leeches,  use  the  ice-bag  or  the  Leiter  coil,  and  follow 
the  cold  by  lead-water  and  laudanum.  After  a  day  or  two 
apply  gentle  pressure,  intermittent  heat,  and  iodin  and 
ichthyol.  If  the  effusion  is  ver}'  great  and  persistent,  and 
pressure,  astringents,  and  sorbefacients  fail,  aspirate  with 
antiseptic  care.  If  effusion  recurs,  apply  a  plaster-of-Paris 
dressing  or  use  flying  blisters  and  massage.  A  rubber  band- 
age is  often  useful  toward  the  termination  of  a  case. 

Chronic  Synovitis. — Chronic  synovitis  follows  acute 
synovitis  or  it  may  be  chronic  from  the  start.  The  syno- 
vial membrane  looks  nearly  natural,  but  is  edematous,  and 
the  joint  contains  an  excess  of  fluid.  If  the  quantity  of 
fluid  is  large,  the  patella  floats  up  and  the  disease  is  called 
"  hydrops  articuli  "  or  "  dropsy."  In  prolonged  cases  the 
synovial  membrane  is  thickened  in  some  places,  softened  in 
others,  and  is  often  adherent,  and  the  villous  processes  of 
the  synovial  membrane  are  hypertrophied.  If  the  membrane 
becomes  extensively  softened  (pulpy  degeneration),  the  soft- 
ened areas  bulge  and  suppuration  eventually  occurs.     In  the 


408  MODERN  SURGERY. 

knee-joint  a  traumatic  synovitis  is  sometimes  linked  with 
inflammation  of  the  semilunar  cartilages.  Roux  tells  us  that 
this  inflammation  may  be  produced  by  a  squeeze,  a  twist,  or 
a  direct  force,  but  a  squeeze  is  the  common  cause.  Hyper- 
extension  of  the  knee  may  squeeze  the  cartilage,  and  so  may 
attempting  to  rise  from  a  stooping  posture.^  If  this  injury 
has  taken  place,  the  condition  of  disability  will  be  prolonged. 

Syjuptonis. — In  chronic  synovitis  pain  is  absent  or  is  only 
present  during  exercise  or  from  pressure,  and  is  slight  even 
then ;  there  is  some  limitation  of  movement ;  passive  motion 
may  develop  creaking  or  crepitus ;  fluctuation  is  apparent ; 
there  is  atrophy  in  the  muscles  about  the  joint;  and  the 
hypodermatic  needle  will  draw  out  a  viscid,  straw-colored 
or  bloody  fluid. 

Treatment. — For  hydrops  use  rest  and  pressure  (a  Martin 
rubber  bandage  or,  better,  a  plaster  dressing),  massage, 
douches,  frictions,  passive  movements,  and  flying  blisters. 
Painting  the  joint  with  iodin  and  spreading  over  it  blue 
ointment,  and  inunctions  with  ichthyol,  may  do  good.  The 
actual  cautery  is  a  valuable  expedient.  Aspiration  and  the 
subsequent  use  of  a  plaster-of- Paris  bandage  may  be  tried  in 
some  cases.  Some  surgeons  advise  aspiration,  washing  out 
with  salt  solution,  injecting  a  5  per  cent,  solution  of  carbolic 
acid,  and  immobilizing.  Incision  and  drainage  constitute  a 
radical  but  proper  plan.  If  pulpy  degeneration  exists,  per- 
form an  excision  or  an  erasion.  If  pus  forms,  incise  at  once 
and  drain.  Internally,  treat  any  existing  diathesis  and  give 
good  food,  tonics,  and  stimulants.  Chronic  synovitis  is  often 
greatly  benefited  by  the  use  of  a  hot-air  apparatus.  The 
affected  part  is  placed  in  the  apparatus  every  day,  and  is 
subjected  to  a  temperature  of  from  250°  to  300°. 

Arthritis. — By  this  term  is  meant  not  only  inflammation 
of  a  synovial  membrane,  but  also  of  other  structures  com- 
posing and  surrounding  a  joint.  It  may  follow  a  traumatic 
synovitis  ;  it  may  be  due  to  pus  organisms,  to  tubercle  bacilli, 
to  infectious  diseases  (gonorrhea  and  typhoid  fever),  to  rheu- 
matism, to  gout,  to  syphilis,  and  to  lesions  of  the  spinal  cord. 
Arthritis  may  be  either  acute  or  chronic. 

Tubercular  Arthritis  (White  Swelling ;  Strumous  Joint ; 
Pulpy  Degeneration). — Patliology  and  Symptoms. — The  ex- 
citing causes  of  tubercular  arthritis  may  be  strains,  blows, 
twists,  or  cold.  The  primary  infection  with  tubercle  bacilli 
is  usually  in  the  bone,  though  it  may  be  in  the  synovial 
membrane,  the  joint-capsule,   or   the  structures  about  the 

1  Gaz.  des  Hop.,  No.  125,  1895. 


DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS.    4O9 

joint.  If  the  primary  infective  focus  is  in  the  bone,  a  portion 
of  the  cartilage  is  destroyed  and  the  joint  is  opened,  or  a 
sinus  forms  and  perforates  the  synovial  membrane.  When 
tubercular  inflammation  attacks  the  synovial  membrane 
granulation-tissue  is  formed,  and  the  capsule  and  periarticu- 
lar structures  soon  become  involved  in  the  process ;  the 
parts  thicken  and  soften  from  caseation,  and  they  may  be 
covered  with  tubercles,  though  but  little  fluid  is  usually 
effused  into  the  joint.  Some  few  cases  present  large  joint- 
effusions.  In  the  ordinary  form  of  arthritis  there  occurs 
what  is  known  as  "  gelatiniform  degeneration  ;"  the  embry- 
onic tissue  is  formed  in  large  amount  as  fungous  growths  ; 
the  structures  are  markedly  edematous  and  softened ;  the 
relaxed  ligaments  yield  under  pressure ;  the  natural  contour 
of  the  joint  is  lost,  and  it  becomes  spindle-shaped ;  all  the 
structures,  articular  and  periarticular,  are  glued  into  one 
mass  ;  the  skin  about  the  joint  is  white,  thick,  and  adherent, 
and  in  it  one  or  more  large  veins  are  seen  ;  fluctuation  or 
pseudo-fluctuation  is  noted  when  caseation  has  occurred ; 
pain  is  not  often  severe,  but  it  can  usually  be  elicited  by 
certain  motions  or  by  firm  pressure  (but  the  pain  will  always 
be  severe  when  the  epiphysis  is  involved) ;  the  temperature 
of  the  part  is  somewhat  elevated ;  deformity  results  from 
destruction  of  bone,  cartilage,  and  ligament,  from  muscular 
spasms,  and  from  the  habitual  assumption  of  certain  attitudes 
to  secure  relief  from  pain;  there  is  soon  impairment  of  joint- 
motions.  When  the  products  of  a  tubercular  arthritis  caseate, 
the  thick  liquid  seeks  exit  by  forming  sinuses  from  which 
caseous  pus  runs.  If  a  sinus  becomes  infected  with  pyo- 
genic cocci,  and  the  joint  itself  becomes  their  prey,  acute 
suppuration  arises  in  the  joint,  and  constitutional  involv^e- 
ment  is  pronounced  and  perilous  to  life. 

In  pannous  synovitis  a  large  effusion  is  formed,  there  is 
but  little  granulation-tissue,  though  the  tubercles  are  present 
in  large  numbers,  and  the  ligaments  and  structures  about  the 
joint  are  slightly  or  not  at  all  implicated.  The  diagnosis 
early  in  a  case  is  difficult,  often  impossible,  and  the  prognosis 
is  grave.  In  only  a  very  few  cases,  even  when  recognized 
early,  is  a  cure  obtained  without  impairment  of  joint-func- 
tion. The  best  that  can  usually  be  accomplished  is  a  cure 
with  more  or  less  ankylosis,  fibrous  or  bony ;  but  often 
ankylosis  is  complete.  Long  after  the  disease  is  apparently 
cured,  it  may  break  forth  anew.  Tubercular  lesions  may 
arise  in  a  distant  organ,  or  general  tuberculosis  may  occur. 
Caseation  is  apt  to  produce  severe  constitutional  disorder. 


4IO  MODERN  SURGERY. 

Infection  by  pus  organisms  gives  rise  to  grave  danger  of 
septicemia.  Death  is  not  unusual  from  exhaustion,  from 
septicemia,  from  disseminated  tuberculosis,  from  tubercle  in 
an  important  organ,  or  from  amyloid  disease. 

Ti'eatment. — Constitutionally,  the  treatment  is  directed 
against  the  tubercular  diathesis.  Locally,  rest  is  of  the 
first  importance,  and  it  is  maintained  for  many  weeks,  it 
being  obtained  by  splints,  by  a  plaster-of-Paris  bandage,  or 
by  extension  appliances.  Bier's  plan  of  inducing  conges- 
tive hyperemia  may  do  good  (page  156).  Aspiration  can 
be  used  for  fluid  accumulations.  Caseous  masses  are  often 
let  alone,  or  an  aspirator  is  used  and  the  joint  drained, 
washed  out  with  boiled  water,  and  injected  with  an  emulsion 
of  iodoform  and  glycerin  (10  per  cent.).  Injections  of  bal- 
sam of  Peru  or  of  iodoform  emulsion  about  the  joint  once 
a  week  are  efficient  in  some  cases.  If  these  means  fail,  if 
the  patient  gets  worse,  or  if  the  condition  of  the  sufferer 
renders  dangerous  the  prolonged  conservative  course,  then 
operate,  removing  the  entire  diseased  area  by  erasion,  by 
excision,  or  by  amputation.  Always  remember  that  an 
incomplete  operation,  a  partial  removal,  is  worse  than  no 
operation,  as  it  opens  the  portals  to  systemic  infection,  and 
may  be  responsible  for  a  general  tuberculosis,  septicemia,  or 
pyemia. 

Tuberculosis  of  Special  Joints. — Tuberculosis  of  the 
Sacro-iliac  Joint  (Sacro-iliac  Disease). — This  is  an  uncom- 
mon affection,  and  is  especially  rare  before  the  age  of  fifteen. 
The  disease  may  begin  in  the  joint,  may  arise  in  adjacent 
bones,  or  may  result  from  a  cold  abscess  burrowing  into 
the  joint.  In  some  cases  it  is  associated  with  extensive 
disease  of  the  pelvic  bones.  The  disease,  if  undetected, 
may  lead  to  dissemination  of  tubercle,  to  abscess,  even  to 
death. 

Symptoms. — Are  often  obscure.  The  disease  is  usually 
confounded  with  vertebral  caries  or  hip-joint  disease.  The 
patient  limps  on  walking,  but  can  stand  on  either  leg ;  there 
is  pain  in  the  sacro-iliac  joint,  about  the  hip,  and  down  the 
thigh ;  tenderness  is  manifest  on  pressure  over  the  joint  and 
on  pushing  the  ilia  together ;  there  is  fulness  over  the  sacro- 
iliac joint ;  but  no  flexion  of  hip  unless  iliac  abscess  exists.^ 

Treatinent. — Rest  in  bed  for  months,  using  also  a  felt  case 
for  pelvis.  Counter-irritation  by  blisters  and  actual  cautery. 
In  some  cases  injection  of  iodoform;  in  others  incision  and 
curetting. 

1  See  A.  G.  Miller,  Edinburgh  Med.  Jour.,  May,  1895. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    4II 

Tuberculosis  of  the  Hip-joint  (Hip  Disease  ;  Morbus  Cox- 
arius ;  Morbus  Coxse ;  Coxitis ;  Hip-joint  Disease). — The  prim- 
ary lesion  may  be  in  the  synovial  membrane,  but  is  more  often 
in  the  bone.  It  may  begin  in  the  acetabulum  ;  it  may  begin  in 
the  femur.  If  it  begins  in  the  femur  it  usually  starts  on  "  the 
distal  side  of  the  epiphyseal  cartilage  "  (Senn).  In  some  cases 
primary  tuberculosis  arises  in  the  trochanter  major,  and  may 
never  involve  the  joint.  When  the  synovial  is  involved  at 
one  point  spreading  throughout  the  joint  is  rapid.  In  many  • 
cases  the  articular  cartilages  are  attacked,  and  in  some  cases 
the  epiphyseal  cartilage  is  destroyed.  It  is  commonest  in 
children,  but  it  may  arise  in  adults  and  even  occasionally  in 
those  of  advanced  years  ;  62  per  cent,  of  cases  arise  in  chil- 
dren under  ten  years  of  age  and  80  per  cent,  of  cases  occur 
before  the  twentieth  year  (Bryant).  Traumatism  and  cold 
may  be  exciting  causes.  The  disease  strongly  tends  to 
caseation  and  the  formation  of  sequestra. 

S}nnptouis. — In  tuberculosis  of  the  hip-joint  there  are 
three  stages:  (i)  the  stage  of  microbic  deposition  and 
multiplication,  the  products  of  the  bacilli  causing  irritation 
and  new  growth ;  (2)  the  stage  of  progression,  with  forma- 
tion of  embryonic-tissue  masses  and  effusion  into  the  joint ; 
and  (3)  the  stage  of  caseation,  with  destruction  of  the  joint 
and  often  of  the  structures  about  it. 

The  symptoms  of  the  first  stage  are  slight  and  may  be 
overlooked  entirely.  In  a  child  there  are  night-terrors ; 
on  getting  about  in  the  morning  the  child  shows  some 
lameness,  which  wears  off  during  the  day,  and  it  soon  grows 
tired  while  playing  and  lies  down  to  rest.  There  may  be 
a  slight  limp  ;  a  slight  adductor  spasm  may  often  be  noted  ; 
some  pain  may  occur  in  the  hip  on  tapping  the  sole  of  the 
foot  while  the  patient  is  recumbent  with  the  leg  extended ; 
pain  may  be  complained  of  at  night  in  the  hip,  in  the  front 
of  the  thigh,  or  at  the  inside  of  the  knee.  The  diagnosis  in 
this  stage  is  more  or  less  problematical. 

In  the  second  stage,  or  the  stage  of  apparent  lengthening, 
the  symptoms  are  positive.  The  child  limps  ;  the  adductor 
muscles  are  rigid ;  the  hip  is  broadened  by  an  effusion  in 
the  joint,  and  fluctuation  may  possibly  be  detected  ;  the  thigh- 
muscles  are  atrophied  ;  the  extremity  is  pushed  forward,  ab- 
ducted, and  everted  (the  patient  tilts  the  pelvis  so  as  to  rest 
his  weight  on  the  sound  limb).  In  some  few  cases  adduction 
exists  rather  than  abduction.  The  abduction,  w'hich  is  usual, 
releases  tension  of  the  fascia  lata,  and  thus  abolishes  pressure 
upon  the  joint  through  pressure  upon  the  trochanter  (Allis). 


412  MODERN  SURGERY. 

The  thigh  is  somewhat  flexed.  This  flexion  relaxes  the  psoas 
muscle  and  prevents  pressure  of  its  tendon  upon  the  front 
of  the  joint  (Allis).  In  very  rare  instances  adduction  is 
present.  Pain  exists,  often  sudden  or  starting,  and  is  located 
in  the  joint,  on  the  front  of  the  thigh,  and  to  the  inner  side 
of  the  knee  in  the  course  of  the  obturator  nerve ;  the  pain  is 
aggravated  at  night ;  and  full  extension  and  complete  abduc- 
tion are  not  possible.  The  gluteal  muscles  waste,  and  the 
gluteal  crease  is  on  a  lower  level  than  is  that  of  the  sound 
side.  The  gluteal  crease  may  be  nearly  or  quite  effaced, 
because  of  hypertrophy  of  the  subcutaneous  layer  (Alexan- 
drofif).  Jarring  of  the  heel  when  the  extremity  is  in  extension 
causes  pain  in  the  hip.  The  above  symptoms  arise  chiefly 
from  unconscious  efforts  to  obtain  ease,  from  joint-effusion, 
reflex  irritation,  and  involuntaiy  or  spasmodic  muscular 
contractions.  Lengthening  in  the  second  stage  is  apparent, 
not  real,  but  this  stage  is  spoken  of  as  the  "  stage  of  length- 
ening." The  position  is  shown  on  Plate  6  (Fig.  4).  The 
fluid  effusion  may  be  absorbed  or  may  find  its  way  externally 
by  means  of  sinuses.  The  latter  condition  is  known  as 
"  abscess  of  the  hip."  The  absorption  of  the  exudate  or 
the  rupture  of  the  capsule  permits  the  contracting  muscles 
to  bring  the  head  of  the  femur  into  firm  contact  with  the 
acetabulum  or  its  brim ;  the  bones  are  worn  away  and 
destroyed,  shortening  results,  abduction  gives  way  to  ad- 
duction, flexion  is  increased,  shortening  occurs,  and  the 
third  stage  is  estabHshed. 

In  the  third  stage  the  head  of  the  femur  goes  upward  and 
outward  upon  the  rim  of  the  acetabulum,  the  thigh  is  flexed 
and  fixed,  and  attempts  at  extension  when  the  patient  is 
recumbent  cause  the  pelvis  to  tilt  forward  and  occasion  a 
marked  lumbar  curve  (PL  6,  Fig.  2),  which  is  due  to  the 
pelvis  moving  with  the  femur  as  if  ankylosed,  and  which 
disappears  on  flexion.  In  the  third  stage  adduction  occurs 
because  of  the  ascent  and  movement  outward  of  the  head 
of  the  bone.  Shortening  is  marked.  After  a  hip- abscess 
finds  an  external  outlet  pyogenic  infection  is  very  apt  to 
take  place  and  inflammation  is  liable  to  arise,  followed  by 
that  state  which  is  designated  as  "  hectic."  If  a  cure  follows 
the  third  stage,  partial  or  complete  ankylosis  takes  place ; 
if  death  ensues,  it  may  be  due  to  septicemia,  tuberculosis  of 
the  viscera,  exhaustion,  or  amyloid  degeneration. 

Diagnosis  is  very  easy  in  well-established  cases  of  hip  dis- 
ease, but  very  difficult  when  the  disease  is  incipient.  Always 
make  a  systematic  and  thorough  examination.     Undress  the 


HIP-JOINT    DISEASE. 


Plate  6. 


I,  2,  Effects  on  the  Lumbar  Spine  of  Flexing  and  Extending  the  Diseased  Leg  in  Hip  Disease 
(Albert).  3,  4.  Positions  in  Coxalgia  (Albert).  5.  Strap-and-slipper  Apparatus  for  Fracture  of  Pos- 
terior Portion  of  the  Calcaneum  (after  Hamilton).  6.  Extension  in  Hip  Disease  (Treves).  7.  Exten- 
sion of  the  Limb  in  a  Flexed  and  Adducted  Position  (Treves).  8.  Extension  of  the  Limb  in  a  Flexed 
and  Abducted  Joint  (Treves). 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    413 

patient  and  place  him  recumbent  upon  a  table  or  a  hard 
mattress,  with  the  legs  extended,  and  note  if  the  heels  are 
level  and  if  the  iliac  spines  are  on  the  same  level  (depressed 
spine  on  the  affected  side  means  abducted  extremity,  the 
degree  of  which  is  determined  by  carrying  the  limb  out  until 
the  spines  are  horizontal ;  elevation  of  the  iliac  spine  on  the 
affected  side  means  adduction,  the  amount  of  which  is  deter- 
mined by  adducting  the  limb  until  the  spines  are  horizontal 
Fig.  loi);  try  all  the  movements  belonging  to  the  joint,  to 


F:g.  ioi. — Positions  in  hip-joint  disease  (after  the  plan  of  Howard  Marsh  and  Treves). 
A. — e /  lumbar  spine  ;  b  d,  limb  fixed  in  flexion  and  abduction — useless  for  wall;ing.  B. — e/, 
lumbar  spine.  Patient  corrects  the  condition  in  B'igure  a  by  curving  the  lumbar  spine  for- 
ward and  rotating  the  pelvis  on  its  transverse  axis,  thus  making  the  femur  point  downward. 
The  lumbar  spine  is  curved  laterally,  the  pelvis  ascending  on  the  sound  side  and  descending 
on  the  affected  side  (apparent  lengthening),  c. — h  li,  limb  fixed  in  flexion  and  adduction. 
D. — e /,  curve  of  lumbar  spine  to  correct  condition  in  Figure  c  (apparent  shortening). 

detect  any  limitations ;  try  if  bringing  down  the  knee  pro- 
duces lordosis  (PI.  6,  Figs,  i,  2);  look  for  sweUing  and  for 
muscular  wasting ;  feel  if  the  head  of  the  bone  is  enlarged ; 
observe  if  motion  produces  pain  or  if  pressure  causes  tender- 
ness ;  and  always  carefully  elicit  the  history  of  the  attack,  of 
the  person,  and  of  the  family. 

Hip  disease  may  be  confounded  with  spinal  caries  in  which 
a  psoas  or  a  lumbar  abscess  has  formed,  with  sacro-iliac  dis- 
ease, with  infantile  paralysis,  with  congenital  dislocation,  with 
lordosis  from  rickets,  with  gluteal  abscess,  and  with  bursitis 
of  the  gluteal  bursae.  In  hip  disease  there  is  always  some 
lameness ;  pain  may  be  severe  or  may  be  absent  entirely, 
and  may  be  in  the  hip  or  be  referred  to  the  front  of  the 
thigh  or  to  the  inner  side  of  the  knee.  Always  remember 
that  the  pain  is  not  characteristic,  and  that  pain  in  the  same 
localities  may  arise  from  aneurysm  of  the  femoral  or  iliac 
arteries,  from  abscess  in  Scarpa's  triangle,  from  caries  of 
the  lumbar  vertebrae,  from  sacro-iliac  disease,  and  from 
cancer  of  the  rectum.  Altered  position  of  the  limb,  limita- 
tion of  movement  in  the  hip-joint,  muscular  w'asting,  and 
swelling  soon  arise  in  hip-joint  disease. 

In  disease  of  the  sacro-iliac  joint  examination  shows  that 


414  MODERN  SURGERY. 

the  movements  of  the  hip-joint  are  unlimited  and  produce  no 
pain,  and  that  pain  is  developed  by  pressure  over  the  sacro- 
iliac articulation  and  by  pressing  the  ilia  together.  In  infan- 
tile paralysis  there  is  no  pain,  but  there  is  paralysis  with  great 
muscular  atrophy,  which  comes  on  with  considerable  rapid- 
ity. In  spinal  caries  with  psoas  abscess  the  evidences  of  dis- 
ease of  the  vertebrae  are  clear  and  the  pus  is  located  in  the 
groin  external  to  the  femoral  vessels.  The  pus  of  hip-abscess 
generally  gathers  under  the  tensor  vaginae  femoris  muscle, 
but  it  may  reach  Scarpa's  triangle  by  passing  through  the 
cotyloid  notch  or  through  the  bursa  under  the  psoas  mus- 
cle ;  it  may  appear  under  the  glutei.  Matter  from  a  caseat- 
ing  acetabulum  may  reach  the  inside  of  the  pelvis  and  appear 
above  Poupart's  ligament. 

In  gluteal  bursitis  the  symptoms  last  for  many  months, 
and  do  not  remit  as  the  symptoms  of  early  hip  disease  are  apt 
to  do.  The  pain  is  but  moderate,  and  is  aggravated  by  ex- 
ercise, but  passes  away  on  going  to  bed,  and  is  felt  back  of 
the  hip  and  back  of  the  knee.  There  are  a  certain  amount 
of  limitation  of  motion  and  a  positive  Hmp,  which  arises 
early.  In  marked  cases  fluctuation  can  be  detected  in  the 
upper  gluteal  region.^ 

Prognosis. — If  the  case  of  hip  disease  is  seen  early,  the 
chances  of  cure  are  excellent  in  children,  in  whom  the  dis- 
ease may  be  arrested  at  any  stage.  The  longer  the  duration 
of  the  disease  and  the  older  the  subject,  the  more  unfavor- 
able is  the  prognosis.  The  cure  takes  many  months,  and 
advanced  cases  only  get  well  by  means  of  ankylosis  with 
shortening  and  deformity.  Hip  disease  may  recur  years  after 
apparent  cure,  and  a  person  who  has  had  hip  disease  runs 
a  strong  chance  of  developing  visceral  tuberculosis. 

Complications. — The  complications  that  may  accompany 
hip  disease  are  the  following :  Abscess,  as  above  noted. 
Tubercular  meningitis,  or  the  condition  known  as  "  acute 
hydrocephalus,"  or  "  water  on  the  brain,"  may  arise  during  the 
progress  of  the  case  or  after  apparent  cure,  and  is  apt  to  en- 
sue upon  incomplete  operations.  It  is  almost  inevitably  fatal. 
Amyloid,  lardaceous,  or  tvaxy  degeneration  of  viscera,  which 
condition  follows  upon  profuse  and  long-continued  suppura- 
tions, and  which  is  apt  to  arise  in  the  liver,  spleen,  kidneys, 
or  intestinal  mucous  membrane.  Tuberculosis  is  not  the  only 
cause,  syphilis  being  responsible  for  at  least  30  per  cent,  of 
all  cases.     In  amyloid  disease  of  the  liver  this  organ  is  much 

1  See  E.  G.  Brackett's  important  paper  on  "  Gluteal  Bursitis,"  in  The  Trans- 
actions of  the  American  Orthopedic  Association,  vol.  x. 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.    415 

enlarged,  smooth,  painless,  and  of  increased  consistency, 
there  is  no  jaundice,  the  spleen  is  apt  to  be  enlarged,  and 
albuminuria  is  the  rule.  In  amyloid  kidney  large  amounts 
of  pale  urine  of  low  specific  gravity  are  voided  ;  albumin  is 
usually  present  in  large  amount,  but  may  be  absent ;  globu- 
lin may  often  be  found,  as  ma)^  also  hyaline,  fatty,  or  granular 
casts  ;  the  patient  is  anemic,  and  dropsy  usually  exists.  Test 
the  hyaHne  casts  with  iodin  for  amyloid  material.  Amyloid 
changes  are  usually  slow  in  onset,  but  they  may  be  rapid ; 
they  are  commoner  in  men  than  in  women,  and  are  most 
frequently  encountered  in  individuals  between  the  ages  of  ten 
and  thirty.  Slight  amyloid  change  may  be  recovered  from, 
but  an  extensive  degeneration  brings  about  a  fatal  result. 
Dickinson's  theory  of  how  this  tissue-change  is  caused  is 
that  the  flow  of  pus  drains  off  from  the  body  the  alkaline 
salts,  especially  the  salts  of  potassium,  which  drainage  re- 
sults in  visceral  depositions  of  de-alkalinized  fibrin.  Phthisis 
puhnonalis  is  a  rare  complication,  but  is  a  common  sequence, 
being  apt  to  arise,  sooner  or  later,  after  the  hip  disease  is 
cured. 

Treatment. — In  the  early  stage  of  hip  disease  the  treatment 
consists  in  rest.  Place  the  patient  upon  a  solid  mattress  and 
apply  extension.  In  children  under  ten  years  of  age,  use  a 
weight  of  from  three  to  five  pounds ;  in  children  between  ten 
and  twenty,  use  a  weight  of  from  five  to  eight  pounds.  A 
long  splint  is  often  applied  to  the  sound  side  to  keep  the 
patient  recumbent  and  horizontal.  Always  use  a  cradle  to 
hold  up  the  bed-clothing.  Apply  the  extension  in  the 
long  axis  of  the  limb,  the  extremity  being  placed  in  the 
line  of  the  deformity  due  to  disease  and  being  supported  by 
pillows.  In  lordosis  from  thigh-flexion,  raise  the  limb  until 
the  iliac  spine  is  straight  (PI.  6,  Fig.  6).  If  the  spine  is  de- 
pressed on  the  affected  side,  abduct  the  limb  (PI.  6,  Fig.  8) ; 
if  the  spine  is  elevated,  adduct  the  limb  until  the  spines  are 
horizontal  (PI.  6,  Fig.  7).  The  object  in  taking  these  precau- 
tions is  to  enable  the  extension  to  separate  the  femoral  head 
and  the  acetabulum.  Extension  will  remove  flexion  in  two 
weeks  in  a  recent  case  and  in  the  course  of  some  months  in 
an  older  case.  As  flexion  is  relieved  remove  the  pillows  and 
lower  the  leg  so  as  to  keep  up  extension  in  the  long  axis 
of  the  thigh.  Abduction  and  adduction  cannot  be  removed 
by  extension. 

Abduction  demands  no  special  treatment.  In  a  movable 
joint  it  will  disappear,  and  in  an  ankylosed  joint  it  is  an  ad- 
vantage, compensating  by  apparent  lengthening  for  the  short- 


4i6 


MODERN  SURGERY. 


ening  due  to  bone-absorption  or  to  stunted  growth  of  the 
limb.  Adduction  requires  an  addition  of  several  pounds  to 
the  extension  weight,  the  use  of  a  long  splint  on  the  sound 
limb,  and  the  drawing  up  of  the  sound  limb  by  a  rope  and 
pulley  toward  the  head  of  the  bed.  The  weight-used  to  pull 
the  sound  side  toward  the  head  of  the  bed  is  equal  to  that 
used  to  pull  the  damaged  side  to  the  foot  of  the  bed.  This 
expedient  is  used  for  a  month  or  six  weeks.  In  old  cases 
where  the  weight  will  not  bring  about 
extension,  anesthetize  the  patient,  gent- 
ly straighten  the  limb  a  very  httle,  and 
reapply  the  weight. 

Extension  in  a  mild  case  must  be 
continued  for  three  months  after  the 
symptoms  have  disappeared,  and  in  a 
severe  case  the  period  must  be  six 
months.  The  weight  is  gradually 
taken  off;  if  symptoms  recur,  the 
weight  is  reapplied ;  if  they  do  not 
recur,  apply  a  traction  splint  or  a 
plaster  dressing,  put  a  high-heeled 
boot  on  the  sound  limb,  and  send  the 
patient  out  on  crutches.  In  young 
children  extension  can  be  made  in  a 
wheeled  carriage,  thus  enabling  the 
patient  to  go  out  in  the  fresh  air  and 
sunlight.  The  general  treatment  is 
tonic  and  restorative.  The  joint  is  so 
deeply  placed  that  it  is  useless  to  make 
In  the  treatment  of  hip  disease 
102)  is    used  by  many,  and  it   may 


Fig.  102. — Thomas's  posterior 
splint. 


external    applications. 

Thomas's  spHnt  (Fig. 

be  combined  with  weight  extension ;  or  Sayre's  splint  (Fig. 

103)  may  be  employed.     Wyeth's  apparatus  (Fig.  104)  is  a 

favorite  with  many  American  surgeons. 

If  the  limb  is  in  good  position,  or  has  been  brought  into 
good  position,  either  by  weight  extension  or  straightening 
under  ether,  plaster-of-Paris  is  a  useful  dressing.  It  is  put 
on  from  the  toes  up,  and  includes  the  entire  extremity  and 
also  the  pelvis.  A  patient  dressed  by  plaster  may  get  about 
on  crutches  when  the  sole  of  the  other  foot  is  raised.  If 
a  case,  in  spite  of  treatment,  does  not  improve  or  becomes 
worse,  use  "  intra-articular  and  parenchymatous  injections  of 
iodoform."  Always  try  these  injections  before  doing  a  resec- 
tion. Sometimes  they  succeed  and  render  resection  unneces- 
sary.    Asepticize  the  surface,  carry  a  small  aspirating-needle 


DISEASES  AND    INJURIES   OE  BONES  AND  JOINTS.    417 

into  the  joint,  irrigate  the  joint  with  salt  solution,  and  inject 
a  sterile  pmulsion  of  iodoform  and  glycerin  (10  per  cent.). 
In  one  week,  if  reaction  has  ceased,  repeat  the  injection.  In 
another  week  repeat  again.  It  may  be  necessary  to  give  from 
ten  to  twenty  injections.  The  spot  for  puncture  is  thus 
obtained :  Draw  a  line  from  a  point  half  an  inch  outside 
of  the  middle  of  Poupart's  ligament  to  the  outer  edge  of 
the  great  trochanter.  Puncture  at  the  middle  of  the  outer 
half  of  this  line  (DeVos). 

If  an  abscess  forms,  incise  it  with  the  most  thorough  anti- 
septic care,  let  the  fluid  drain  away,  wash  out  with  salt  solu- 


FiG.  103. — Sayre's  long  splint. 


Fig.  104. — Wyeth's  combination  method. 


tion,  remove  any  sequestra,  inject  with  iodoform  emulsion, 
insert  a  tube,  and  dress  antiseptically.  In  some  cases  the 
sequestrum  is  extra-articular.  In  some  cases  no  sequestrum 
is  found.  The  old  plan  of  not  operating  until  rupture  was 
seen  to  be  inevitable  was  bad.  To  open  early  and  antisepti- 
cally often  means  rapid  healing,  the  prevention  of  burrowing, 
a  lessened  danger  of  visceral  infection,  and  an  earlier  cure. 

27 


41 8  MODERN  SURGERY. 

Hectic  will  not  arise  if  the  abscess  is  opened  with  antiseptic 
care. 

Excision  of  the  hip  is  to  be  performed  when  the  head  of 
the  femur  is  detached  and  lies  loose  in  the  joint ;  when  pro- 
fuse suppuration  continues  for  a  long  time,  and  other  methods 
fail  to  arrest  it ;  when  amyloid  disease  is  beginning ;  or  when 
very  faulty  position  is  inevitable  without  operation.  Excision 
is  an  operation  of  considerable  danger,  and  the  older  the 
person  the  greater  the  danger.  Schede  advocates  arthrec- 
tomy  in  some  cases  as  a  substitute  for  resection.  Senn  tells 
us  that  opinion  as  to  resection  has  greatly  changed  of  late, 
and  the  operation  is  advisable  in  all  cases  where  fixation,  ex- 
tension, intra-articular  and  parenchymatous  injections  have 
failed  to  arrest  the  disease  (see  Tuberculosis  of  Bones  and 
Joints).  When  there  is  extensive  disease  of  the  femur,  when 
excision  has  been  tried  and  has  failed,  and  when  the  patient 
has  not  the  recuperative  power  to  stand  the  long  siege 
following  excision,  amputate.^ 

Knee-joint  Disease  (White  Swelling). — After  the  hip,  the 
knee  is,  of  all  joints,  the  commonest  site  for  tubercular  dis- 
ease. Knee-joint  disease  can  begin  as  a  synovitis,  but  oftener 
begins  as  tubercular  inflammation  of  the  femoral  or  the 
tibial  epiphysis.  The  disease  rarely  attacks  the  bone  above 
the  epiphyseal  line  ;  a  single  focus  only  exists  as  a  rule,  and  a 
sequestrum  is  rarely  formed.  In  very  rare  instances  the  pa- 
tella is  primarily  attacked,  or  the  semilunar  cartilages.  It  may 
begin  at  any  age,  but  is  most  common  in  children  and  young 
adults.  If  an  acute  synovitis  ushers  in  the  case,  there  may 
be  large  eflusion  into  the  knee-joint  and  partial  flexion,  but 
swelling  is  usually  slight  in  knee-joint  disease.  Pulpy  de- 
generation of  the  .synovial  membrane  occurs ;  the  joint 
enlarges ;  the  ligaments  soften ;  the  skin  is  edematous ; 
muscular  spasm  is  marked ;  the  leg  is  flexed ;  the  bones  are 
displaced  backward  and  outward,  the  foot  being  everted; 
lameness  exists,  due  chiefly  to  deformity;  pain  may  be 
absent,  is  often  slight,  and  is  rarely  severe.  When  the  disease 
begins  in  the  bone  or  an  epiphysis  ther6  are  pain,  tenderness, 
lameness,  swelling,  inability  to  extend  the  hmb  completely, 
sudden  spasmodic  muscular  contractions,  and  final  involve- 
ment of  the  joint.  When  an  abscess  forms,  it  may  destroy 
the  joint  very  rapidly  or  it  may  break  externally. 

Treatment. — In  treating  knee-joint  disease  employ  general 
antitubercular  treatment  and  locally  apply  iodoform  oint- 
ment or  guaiacol.     Apply  splints  (Figs.  105,  106),  extension 

1  See  the  admirable  article  of  Howard  Marsh  in  Treves's  Manual  of  Surgery. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    419 


(Fig.  107),  or  a  plaster-of- Paris  bandage,  and  keep  the  patient 
in  bed  for  a  few  weeks ;  then  permit  him  to  go  out  upon 
crutches,  with  a  high-heeled 
shoe  upon  the  sound  foot. 
In  cases  in  which  treatment 
is  begun  early  the  disease 
may  often  be  arrested  in  from 
eight  to  twelve  months.  If 
the  symptoms  do  not  abate 
after  a  number  of  weeks,  or 
if  the  condition  grows  worse 
and  an  abscess  arises,  aspirate, 
irrigate,  and  inject  iodoform 
emulsion.  Intra-articular  in- 
jections are  not  unusually 
curative.  Insert  the  needle 
in  the  angle  between  the 
outer  edge  of  the  patella  and 
the  ligament  of  the  patella 
(DeVos).  Repeat  the  injec- 
tion in  one  week  if  reaction 
has  abated,  and  advance   as 

directed  for  the  injection  of  the  hip-joint.  Some  surgeons 
incise  the  capsule,  remove  all  fragments  and  tubercular 
foci,  irrigate  with  normal  salt  solution,  inject  iodoform 
emulsion,  and  sew  up  without  drainage  (Neuber's  plan).  If 
these  means  fail,  open  the  joint  and  perform  an  excision  or 
an  erasion  (page  495).     Some    cases    demand  amputation, 


Fig.  105. — Sayre's     Fig.  io6. — Hutchinson's 
knee  splint  applied.  knee-joint  splint. 


Sayre's  double  extension  of  the  knee-joint. 


which,  if  the  patient's  health  is  much  impaired,  is  to  be 
preferred  to  excision.  Amputation  is  preferred  to  excision 
in  very  young  children  and  aged  people. 

Ankle-joint  disease  may  begin  in  the  synovial  membrane, 


420  MODERN  SURGERY. 

in  the  tibial  epiphysis,  or  in  the  tarsus,  but  the  origin  is 
usually  synovial.  The  symptoms  are  pain,  swelling,  lame- 
ness, limitation  of  joint-movements,  and  atrophy  of  the  calf- 
muscles.     Suppuration  often  occurs,  and  sinuses  form. 

Treatment. — The  treatment  of  ankle-joint  disease  consists 
in  the  employment  of  antitubercular  remedies,  applications 
of  guaiacol  or  iodoform  ointment  over  the  joint,  and  rest  by 
means  of  splints  or  plaster.  Caution  the  patient  to  avoid 
standing  upon  the  diseased  extremity.  Injections  of  iodoform 
emulsion  may  do  good.  Insert  the  needle  below  the  outer 
malleolus.  When  caseation  occurs,  it  is  often  advisable  to 
open,  drain,  wash  out  with  normal  salt  solution,  inject  iodo- 
form emulsion,  and  put  up  the  ankle-joint  in  plaster.  When 
joint-disorganization  occurs,  perform  an  excision  or  an 
erasion.  Some  cases  demand  amputation  (Syme's  amputa- 
tion being  preferred  by  some,  amputation  above  the  ankle 
being  approved  by  many).  Osteoplastic  resection  is  some- 
times advised  (Wladimiroff-Mikulicz  operation). 

Shoulder-joint  disease  is  not  common ;  it  is  rare  in  chil- 
dren and  is  commonest  in  adults ;  it  begins  either  in  the 
synovial  membrane  or  in  the  head  of  the  humerus.  The  gle- 
noid cavity  is  rarely  attacked.  Pain  is  slight,  atrophy  of  the 
deltoid  and  other  muscles  is  noted,  the  joint  is  stiff,  and  the 
scapula  follows  the  motions  of  the  humerus.  Caries  sicca  is 
the  usual  cause  of  destruction.  In  many  cases  swelling  is 
not  obvious,  the  joint  shrinking  because  of  destruction  of  the 
head  of  the  bone  and  contraction  of  the  capsule  (Senn).  If 
an  abscess  forms,  it  may  open  in  the  axilla  under  the  deltoid, 
or  at  some  far  distant  point,  but  abscess-formation  is  unusual. 

Treatment. — In  treating  shoulder-joint  disease  employ  anti- 
tubercular  remedies  and  apply  over  the  joint  guaiacol  or  iodo- 
form ointment.  Put  on  a  shoulder-cap,  apply  the  second 
roller  of  Desault,  and  hang  the  hand  in  a  sling.  Maintain 
rest  for  at  least  four  months.  Aspiration  and  injection  of 
iodoform  emulsion  are  very  valuable  in  synovial  tuberculosis.. 
The  needle  is  entered  below  the  acromion,  while  the  arm  is 
held  against  the  side  and  the  forearm  is  at  right  angles  to 
the  arm  and  across  the  front  of  the  chest  (DeVos).  If  an 
abscess  forms,  open  and  drain  it.  In  rare  instances  dead 
bone  will  have  to  be  gouged  away.  Caries  sicca  may 
occur.     Excision  is  sometimes  required. 

Elbow-joint  disease  may  begin  in  the  humerus  or  the 
ulna.  The  head  of  the  radius  is  rarely  the  primary  focus. 
In  some  cases  the  synovial  membrane  is  first  attacked.  It  is 
most  frequent  in   young  adults.     The  joint   is  swollen,  its 


DISEASES  AND  INJURIES    OF  BONES  AND  JOINTS.    42 1 

movements  are  somewhat  limited,  the  skin  is  usually  hot, 
muscular  wasting  is  pronounced,  and  pain  is  generally  slight. 
Pus  may  form. 

Trcalmoit. — In  treating  elbow-joint  disease,  employ  anti- 
tubercular  foods,  drugs,  and  hygienic  measures ;  iodoform 
ointment  or  guaiacol  locally ;  rest  by  means  of  an  anterior 
angular  splint  (Fig.  108)  and  a  triangular  sling.    Injection  of 


Fig.   108. — Stromeyer's  anterior  angular  splint. 

iodoform  emulsion  may  be  useful.  Insert  the  needle  for 
injection  by  the  side  of  the  olecranon.  If  caseation  takes 
place,  it  is  often  necessary  to  open  the  joint  and  drain. 
Splints  are  to  be  worn  for  from  four  months  to  a  year.  If 
any  considerable  area  becomes  carious,  perform  an  erasion 
or  an  excision. 

"Wrist-joint  disease  may  arise  at  any  age,  and  is  some- 
times met  with  in  late  middle  life,  or  even  in  old  age.  The 
joint  presents  a  puffy  swelling,  loses  its  normal  contour,  and 
becomes  spindle-shaped.  Hand-movements  are  impaired, 
pronation  and  supination  cannot  completely  or  satisfactorily 
be  performed,  the  joint  is  stiff  and  partly  flexed,  the  grasp  is 
enfeebled,  pain  may  be  severe  or  slight,  the  skin  is  usually 
hot,  and  muscular  atrophy  is  marked.  This  form  of  tuber- 
culosis may  begin  in  the  synovial  membrane,  in  the  bones,  or 
in  the  tendon  sheaths. 

TrcaUncnt. — The  essential  treatment  in  wrist-joint  disease 
comprises  cod-liver  oil,  tonics,  good  food  and  fresh  air,  and 
the  local  application  of  guaiacol  or  iodoform  ointment.  Ap- 
ply a  Bond  splint  and  sling  or  put  on  a  plaster  bandage,  and 
maintain  rigid  rest  for  from  four  to  six  months.  Aspiration 
and  injection  of  iodoform  emulsion  is  often  useful.  Enter  the 
needle  at  the  dorsal  edge  of  the  radial,  styloid  process,  and 
again  at  the  upper  edge  of  the  pisiform  bone  (DeVos).  In 
some  cases  it  is  well  to  incise,  wash  with  salt  solution,  in- 
ject iodoform  emulsion,  and  close  without  drainage.  Severe 
cases  demand  incision  and  drainage  with  the  maintenance  of 


422  MODERN  SURGERY. 

rest.  A  moderate  amount  of  caries  is  treated  by  drainage 
and  rest.  Necrosis  demands  removal  of  the  sequestra.  Ex- 
tensive caries  requires  excision. 

Acute  Suppurative  Arthritis. — This  infection  is  usually 
due  to  the  staphylococcus  pyogenes  aureus  or  to  the  strepto- 
coccus pyogenes  which  find  entrance  by  means  of  a  wound, 
by  the  spontaneous  evacuation  into  a  joint  of  the  products 
of  an  osteomyeHtis,  by  extension  of  suppurative  inflammation 
through  contiguous  structures,  or  by  the  blood-stream.  In 
this  disease  all  the  joint-structures  are  involved  and  suppura- 
tion rapidly  appears.  It  is  very  rarely  due  to  gonorrhea,  and 
sometimes  to  septicemia. 

Symptouis. — The  symptoms  of  septic  arthritis  are — fever, 
high  pulse,  sometimes  a  chill,  severe  pain,  which  is  aggra- 
vated by  motion  and  is  worse  at  night ;  discoloration,  heat, 
and  edema  of  the  skin;  partial  flexion  of  the  joint;  fluctua- 
tion; and  marked  constitutional  symptoms  of  sepsis.  The 
joint  tends  to  rapid  disorganization,  and  fatal  septicemia  is 
very  apt  to  occur.  In  pyemic  arthritis  several  joints  become 
infected. 

Treatment. — The  treatment  in  septic  arthritis  consists  in 
prompt  incision,  evacuation,  antiseptic  irrigation,  drainage, 
antiseptic  dressing,  and  immobilization..  Cure  is  followed, 
as  a  rule,  by  ankylosis,  but  in  cases  treated  early  the  joint 
may  be  preserved. 

Infective  arthritis  arises  in  the  course  of  an  acute  infec- 
tious disease  (such  as  erysipelas,  typhoid  fever,  influenza, 
mumps,  dysentery,  diphtheria,  measles,  scarlatina,  variola), 
and  may  be  due  to  pyogenic  cocci  or  to  the  specific  micro- 
organism of  the  acute  infectious  disease.  Joint-inflammation 
arising  in  the  course,  or  as  a  sequel,  of  an  acute  infectious 
disease  may  or  may  not  suppurate. 

Symptoms  and  Treatment. — If  no  suppuration  takes  place, 
the  symptoms  of  the  attack  resemble  those  of  rheumatism ; 
if  suppuration  occurs,  the  symptoms  are  identical  with  those 
of  septic  arthritis.  Suppuration  rarely  occurs.  Ashby  has 
well  described  the  arthritis  which  sometimes  follows  scarla- 
tina. It  involves  wrists,  finger-joints,  tendons  of  forearm, 
knees,  ankles,  or  spine.  The  joints  are  painful,  but  are 
rarely  much  swollen  or  discolored  (Howard  Marsh). 

That  the  organism  of  typhoid  may  inflame  the  joints  is 
proved  (Klemm,  Quincke,  and  others),  but  whether  it  does 
cause  suppuration  is  not  so  certain.  Some  claim  that  mixed 
infection  induces  suppuration.  The  typhoid  bacilli  enter  the 
bones  in  many  typhoid  cases  and  sometimes  cause  bone  dis- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    423 

ease.  Joint  disease  is  more  common  than  bone  disease.  A 
typhoid  joint  begins  when  the  fever  is  abating,  and  more  than 
one  joint  may  be  involved.  These  joints  may  recover  per- 
manently, may  ankylose,  may  dislocate,  or  may  lead  to  a 
fatal  sepsis.  We  may  tell  this  disease  from  rheumatism  by 
the  fact  that  it  does  not  migrate,  and  is  uninfluenced  by  anti- 
rheumatic remedies.  In  slight  cases  the  synovial  membrane 
only  is  involved ;  in  more  severe  cases  capsule,  cartilage, 
ligament,  and  even  bones  are  involved.  Some  cases  sup- 
purate. Keen  tells  us  that  septic  typhoid  arthritis  results 
from  a  mixed  infection  with  typhoid  bacilli  and  pyogenic 
bacteria,  and  is  identical  in  symptoms  and  progress  with  an 
ordinary  septic  arthritis.  The  same  author  points  out  that 
typhoid  arthritis  proper  may  be  monarticular  or  polyarticular, 
the  monarticular  form  being  the  most  common,  and  the  hip- 
joint  being  the  articulation  most  liable  to  attack.  In  most 
cases  typhoid  arthritis  causes  but  little  pain.  The  swelling 
is  marked,  although  in  the  hip  it  is  concealed.  Pus  rarely 
forms.  Keen  calls  attention  to  the  fact  that  in  the  eighty- 
four  cases  he  collected,  spontaneous  dislocation  occurred  in 
forty-three,  nearly  all  in  the  hip.^ 

Treatment  of  a  mild  case,  as  for  simple  synovitis  :  if  there 
is  much  fluid  in  the  joint,  aspirate  and  wash  out  with  normal 
salt  solution.     If  pus  forms,  open,  irrigate,  and  drain. 

Gonorrheal  Arthritis,  or  Gonorrheal  Rheumatism. — 
During  the  progress  of  gonorrhea  every  rheumatic  attack 
is  not  gonorrheal  rheumatism,  for  ordinary  rheumatism  is 
just  as  likely  to  arise  when  a  man  has  clap  as  when  he  has 
not  this  malady.  Furthermore,  the  term  is  inaccurate,  as 
gonorrheal  rheumatism  is  not  rheumatism  at  all,  but  is  an 
infecti\-e  disorder  of  the  joints  or  of  the  synovial  membranes, 
the  infective  material  being  contained  primarily  in  the  urethral 
discharge.  Occasionally  this  form  of  arthritis  arises  from 
gonorrheal  ophthalmia  (Heiman's  case).  This  infective  ar- 
thritis sometimes,  though  rarely,  arises  during  the  height  of 
a  gonorrhea,  but  is  more  frequently  met  with  in  chronic  cases 
or  when  the  intensit}'  of  the  inflammation  is  abating  in  acute 
cases.  Men  suffer  from  gonorrheal  arthritis  far  more  fre- 
quently than  do  women,  and  the  seizure  is  very  apt  to  recur 
again  and  again.  In  some  cases  many  joints  are  involved, 
but  in  most  cases  only  a  few  joints  suffer.  Osier  states  that 
the  knees  and  ankles  are  most  apt  to  be  involved  in  a  gonor- 
rheal rheumatism,  and  that  this  form  of  arthritis  is  peculiar 
in  often  attacking  joints  that  are  apt  to  be  exempt  in  acute 

'  Keen  on  The  Surgical  Complications  and  Sequels  of  Typhoid  Fever. 


424  MODERN  SURGERY. 

rheumatism  ("  the  sternoclavicular,  the  intervertebral,  the 
temporomaxillary,  and  the  sacro-iliac  "). 

Changes  In  and  About  the  Joint. — The  inflammation  of 
gonorrheal  arthritis  may  be  located  around  rather  than  in 
the  joint,  and  especially  in  the  tendon-sheaths.  Suppuration 
is  unusual,  but  it  may  occur  in  joints  and  in  tendon-sheaths. 
Cultivation  of  the  exudate  may  or  may  not  show  the  gono- 
cocci.  Cover-glass  preparations  stained  by  Gram's  method 
may  show  gonococci.  Osier  suggests  that  the  non-suppura- 
tive  cases  are  due  to  the  action  of  toxins  taken  up  from  the 
area  of  primary  infection,  and  that  the  suppurative  cases  are 
due  to  infection  with  pyogenic  bacteria. 

Symptoms. — In  gonorrheal  arthritis  there  may  be  transi- 
tory, intermittent,  and  wandering  pains  in  and  about  the 
joint,  without  any  other  symptom ;  one  or  more  joints  may 
become  swollen  and  painful,  and  moderate  fever  may  develop. 
An  acute  inflammation  with  intense  pain  and  great  swelling 
may  attack  a  single  joint,  in  which  case  fever  will  be  mod- 
erate unless  suppuration  follows.  One  joint,  especially  the 
knee,  may  swell  to  an  enormous  extent,  pain,  periarticular 
edema,  redness,  and  fever  being  absent  (hydrarthrosis,  or 
drop.sy  of  a  joint).  Suppuration  in  this  form  is  rare.  The 
tendons,  the  tendon-sheaths,  the  bursae,  and  the  periosteum 
may  inflame.  A  case  of  gonorrheal  arthritis  is  often  very 
hard  to  check.  It  may  last  for  a  long  period,  and  tends 
to  recur  again  and  again.  Iritis,  pleuritis,  endocarditis,  and 
pericarditis  have  been  observed  as  complications. 

The  diagnosis  between  gonorrheal  arthritis  and  acute 
rheumatism  rests  chiefly  on  the  great  chronicity,  the  slight 
degree  of  fever,  the  excessive  tendency  to  recurrence,  and 
the  absence  of  profuse  acid  sweats  in  gonorrheal  rheuma- 
tism ;  and  on  the  shorter  course,  the  higher  fever,  the  pro- 
fuse acid  sweats,  the  lesser  tendency  to  rapid  recurrence, 
the  greater  proneness  to  symmetrical  involvement,  and  the 
great  liability  to  cardiac  and  visceral  complications  in  rheu- 
matic fever.  Furthermore,  in  gonorrheal  arthritis  a  gonor- 
rheal infection  (urethral  or  ocular)  certainly  exists  or  recently 
existed ;  in  ordinary  rheumatism  a  urethral  discharge  may, 
of  course,  happen  to  be  present.  Gonorrheal  arthritis  is 
apt  to  affect  certain  joints  which  acute  rheumatism  rarely 
attacks. 

Treatment. — Internally,  in  treating  gonorrheal  arthritis,  the 
salicylates,  the  alkalies,  salol,  and  iodid  of  potassium  are  use- 
less ;  iron,  arsenic,  and  strychnin  are  of  some  benefit.  Quinin 
is  distinctly  helpful  in  some  cases.     In  suppurative  cases  in- 


D/SEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    425 

cise  and  drain  (sec  Septic  Arthritis,  page  422).  In  non-sup- 
purativc  cases  treat  as  in  simple  synovitis  (page  406).  In 
lingering  cases  employ  the  hot-air  bath,  massage,  passive 
motion,  flying  blisters,  or  the  hot  iron ;  if  these  means  fail, 
open  the  joint,  wash  it  out  with  some  antiseptic  fluid,  and 
dress  antiseptically,  or  aspirate  and  irrigate  with  hot  normal 
salt  solution. 

Rheumatic  Arthritis. — Acute  rheumatism  is  a  self-limited 
febrile  malady  whose  characteristic  features  are  polyarthritis, 
profuse  acid  sweats,  and  a  tendency  to  heart-involvement. 

Symptoms  of  Acute  Rheumatism. — In  acute  rheumatism  the 
case  begins  with  malaise  and  fever,  and  one  or  more  joints 
become  affected.  The  inflammation  spreads  from  joint  to 
joint,  is  apt  to  be  symmetrical,  and  when  it  arises  in  fresh 
joints  usually  disappears  quickly  in  those  previously  af- 
fected. The  temperature  is  high,  the  skin  sweats  profusely, 
the  joints  are  red,  swollen,  hot,  and  excruciatingly  painful, 
and  the  structures  about  the  joints  are  edematous.  After  a 
short  time  the  inflammation  subsides  in  one  joint  and  passes 
into  another,  the  joint  first  attacked  regaining  its  functions. 
Suppuration  does  not  take  place.  Anemia  is  pronounced, 
exhaustion  is  profound,  the  sweat  is  sour,  the  saliva  is  acid; 
the  urine  is  acid,  scanty,  high-colored,  often  contains  albu- 
min, and  is  deficient  in  chlorids.  Cardiac  disease  is  apt  to  be 
produced  (endocarditis,  pericarditis,  or  myocarditis).  Nodules 
may  form  upon  fibrous  structures,  hyperpyrexia  is  not  un- 
usual, and  cerebral  or  pulmonary  complications  may  occur. 

Chronic  rlieiimatism  rarely  follows  repeated  attacks  of  acute 
rheumatism,  but  rather  arises  insidiously  in  people  who  have 
been  exposed  to  cold  and  damp,  who  have  suffered  from 
poverty,  hardship,  and  priv^ation,  or  who  have  had  much 
worry.  The  capsule  and  the  tendon-sheaths  thicken,  and 
there  is  usually  but  little  effusion  in  the  joint,  but  the  ar- 
ticulation becomes  stiff  and  painful.  The  joint-cartilages  are 
occasionally  eroded.     Muscular  atrophy  occurs. 

Symptoms  of  Clironic  RJieiimatism. — In  chronic  rheuma- 
tism the  affected  joints  are  stiff  and  painful  and  are  a 
little  swollen,  but  not  red.  Dampness  and  cold  aggravate 
the  symptoms.  One  joint  or  many  may  be  affected,  but 
usually  many  are  involved.  Passive  movements  cause  the 
joint  to  creak  and  develop  crepitus  in  the  tendon-sheaths. 
The  muscles  are  wasted.  The  joints  may  ankylose.  Anemia 
is  usually  pronounced.  There  is  no  fever  and  no  tendency 
to  suppuration,  and  the  disease  is  incurable. 

The  treatment  in  acute  rheumatism  comprises  the  use  of 


426  MODERN  SURGERY. 

alkalies,  salicylates,  etc.  (See  a  book  upon  medicine,  as  acute 
rheumatism  is  in  the  physician's  province.)  In  chronic 
rheumatism  maintain  the  general  health  of  the  patient,  give 
courses  of  iron,  arsenic,  and  strychnin,  and  an  occasional 
course  of  iodid  of  potassium  or  a  salt  of  lithium,  and,  if 
possible,  send  him  every  winter  to  a  warm  climate.  Turkish 
baths  give  considerable  temporary  relief  The  waters  and 
regimen  of  Carlsbad  and  Vichy  are  of  positive  though  tem- 
porary benefit,  and  the  sufferer  may  obtain  relief  at  the  hot 
springs  of  Virginia.  The  patient  must  avoid  damp  and 
must  wear  woollens.  Frictions,  the  douche,  massage,  flying 
blisters,  counter-irritation  with  the  hot  iron,  ichthyol  oint- 
ment, and  mercurial  ointment  are  of  benefit.  Subjecting  the 
diseased  joint  to  a  very  high  temperature  by  placing  it  daily 
in  a  special  apparatus  often  does  great  good.  In  partial  anky- 
losis give  ether  and  break  up  the  adhesions. 

Gouty  arthritis,  which  appears  especially  in  the  smaller 
joints  (as  the  fingers  and  the  metatarsophalangeal  joint  of 
the  big  toe),  is  due  to  a  deposition  of  urate  of  sodium  in  the 
joint  and  in  the  periarticular  structures.  The  irritant  urate 
of  sodium  causes  inflammation,  inflammation  forms  embry- 
onic tissue,  embryonic  tissue  is  converted  into  fibrous  tissue, 
and  the  fibrous  tissue  contracts  and  thus  deforms  the  joint 
and  limits  its  mobility.  A  great  mass  of  urates  in  a  joint 
constitutes  a  "  chalk-stone." 

Symptoms. — The  premonitory  symptoms  may  be  observed 
for  a  day  or  so,  but  the  acute  seizure  occurs  early  in  the 
morning,  the  patient,  as  a  rule,  being  aroused  by  excruciat- 
ing pain  in  the  metatarsophalangeal  articulation  of  the  great 
toe.  The  joint  swells,  and  the  skin  over  it  feels  hot  to  the 
hand  and  becomes  red  and  shiny.  There  is  often  considerable 
fever.  After  a  few  hours  the  intensity  of  the  seizure  abates, 
only  to  recur  again  with  renewed  violence  early  the  next 
morning,  these  remissions  and  recurrences  taking  place  for 
six  or  eight  days,  when  the  attack  subsides.  In  patients  with 
chronic  gout  many  joints  are  stiffened  and  deformed  as  a  re- 
sult of  repeated  attacks.  Chalk-stones  form,  and  the  skin 
above  them  may  ulcerate.  Such  patients  are  chronic  dys- 
peptics, have  high-tension  pulses,  their  hearts  are  hyper- 
trophied,  and  their  urine  contains  albumin  and  casts. 

The  treatment  of  gouty  arthritis  belongs  to  the  physician, 
and  not  to  the  surgeon,  although  to  the  latter  the  symptoms 
of  the  disease  should  be  known,  so  that  it  may  be  diagnosti- 
cated from  other  maladies. 

Arthritis    Deformans  (Rheumatoid   Arthritis ;    Osteo-ar- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    427 

thritis  ;  Rheumatic  Gout ;  Paget's  Disease). — In  this  disease, 
which  is  not  a  combination  of  gout  and  rheumatism,  the 
synovial  membrane  and  cartilages  are  affected,  the  peri- 
articular structures  are  involved,  and  masses  of  new  bone 
are  formed. 

Arthritis  deformans  has,  as  John  K.  Mitchell  pointed 
out,  a  probable  nervous  origin.  It  arises  especially  in  per- 
sons who  have  been  worried,  driven,  and  harassed.  There 
is  apt  to  be  muscular  atrophy ;  trophic  lesions  of  the  hair 
and  nails  are  likely  to  occur,  and  the  symptoms  are  dis- 
posed to  be  symmetrical.  The  causative  lesion  has  not  been 
determined.  Rheumatic  gout  is  commoner  in  women  than 
in  men.  The  greatest  liability  exists  between  the  ages  of 
twenty  and  thirty,  but  children  may  acquire  the  disease,  and 
it  may  also  be  developed  in  people  beyond  middle  life. 
Apes  in  captivity  ma\-  develop  it.  Arthritis  deformans  may 
attack  the  rich  or  the  poor ;  it  does  not  result  from  gout,  nor 
does  it  often  follow  rheumatism  ;  it  is  not  caused  by  damp 
and  cold  ;  and  it  does  not  arise  from  traumatism. 

Arthritis  deformans  differs  from  gout  in  the  entire  absence 
of  urate  deposit,  and  it  differs  from  chronic  rheumatism  in 
the  extensive  alterations  in  the  joint-structures.  The  changes 
begin  in  the  cartilage ;  the  cartilage-cells  multiply,  the  inter- 
cellular substance  degenerates,  the  pressure  of  the  bone  causes 
thinning,  and  at  length  the  cartilage  is  entirely  destroyed 
and  the  bone  is  exposed.  The  exposed  bone  is  altered  in 
shape,  is  hardened,  and  is  worn  away  in  the  centre,  the 
periphery  increasing  in  thickness  by  ossific  deposit ;  thus 
the  center  becomes  deepened  by  absorption  and  the  periphery 
bulged  and  lengthened  by  deposit.  The  fringes  of  the  syno- 
vial membrane  hypertrophy  and  multiply,  and  some  of  them 
are  apt  to  break  off  (loose  cartilages).  The  capsule  and  the 
ligaments  of  the  joint,  as  a  rule,  become  fibrous  and  con- 
tract, but  they  may  soften,  relax,  and  permit  of  dislocation. 
The  joint  usually  contains  no  effusion,  but  in  some  cases 
there  is  great  effusion  (hydrarthrosis).  The  tendons  about 
the  joint  may  become  fibrous  and  contracted,  they  may 
ossify,  they  may  be  separated  from  the  bone,  or  they  may 
be  destroyed  entirely.  Deformity  is  marked  and  motion  is 
limited.  The  fingers,  when  involved,  show  nodules  on  the 
sides  of  the  joints  (Heberden's  nodules).  The  vertebrae 
may  be  involved.  Almost  all  the  joints  may  suffer.  Sup- 
puration does  not  occur. 

Symptoms. — Charcot  classifies  arthritis  deformans  into 
three  forms,  and  giv^es  their  symptoms  as  follows  : 


428  MODERN  SURGERY. 

(i)  Heberden's  nodosities,  which  condition  is  commoner  in 
women  than  in  men,  comes  on  between  the  ages  of  thirty 
and  forty,  and  is  especially  common  in  neurotic  subjects. 
The  interphalangeal  joints  become  the  victims  of  attacks  of 
moderate  swelling  and  of  some  tenderness,  which  attacks 
are  not  severe,  but  recur  again  and  again.  After  a  time 
small  hard  swellings  (nodosities)  appear  upon  the  sides  of 
the  dorsal  surfaces  of  the  second  and  third  phalanges,  re- 
main permanently,  and  slowly  increase  in  size.  The  joints 
become  stiff  and  creak  on  movement,  the  cartilages  are  de- 
stroyed, and  contractions  and  rigidity  develop,  but  there  is 
no  fever  and  the  larger  joints  are  not  involved.  The  malady 
is  incurable. 

(2)  Progressive  rheumatic  gout,  which  may  be  acute  or 
chronic.  The  acute  form  begins  as  does  rheumatic  fever. 
There  are  moderate  fever,  and  swelling,  without  redness,  of 
a  number  of  joints,  of  bursae,  and  of  tendon-sheaths ;  the 
joints  are  stiff  and  crepitate,  and  are  apt  to  be  symmetrically 
involved ;  muscular  atrophy  begins  early  and  rapidly  be- 
comes decided ;  pain  is  slight.  This  acute  form  is  apt  to 
arise  in  young  women  after  pregnancy,  but  is  not  unusual  at 
the  climacteric  and  in  children.  Anemia  always  exists.  The 
case  is  apt  to  advance  progressively  until  a  number  of  joints 
are  firmly  locked,  when  it  may  become  stationary.  Another 
pregnancy  will  develop  anew  the  acute  symptoms.  In  the 
chronic  form  swelling  and  pain  on  movement  are  noted  in 
certain  joints.  The  involvement  is  apt  to  be  symmetrical. 
Attacks  of  swelling  and  pain  alternate  with  periods  of  quies- 
cence, but  the  disease  does  not  cease  its  advance.  Articu- 
lation after  articulation  is  attacked  by  the  malady  until  almost 
all  the  joints  are  involved ;  deformity  and  stiffness  become 
pronounced,  and  pain  may  or  may  not  be  severe.  There  is 
no  fever.     Muscular  atrophy  is  marked. 

(3)  Partial  rheumatic  gout  attacks  one  articulation,  and  it 
is  most  often  met  with  in  old  men.  It  may  fix  itself  on  the 
vertebral  column,  on  the  knee,  on  the  shoulder,  on  the 
elbow,  or  on  the  hip.  The  joint  grates,  and  becomes  stiff, 
swollen,  and  deformed ;  the  muscles  atrophy ;  there  is 
usually  pain,  but  fever  is  absent.  Partial  rheumatic  gout 
of  the  hip-joint  in  an  old  person  is  known  as  "morbus  coxae 
senilis,"  and  partial  rheumatic  gout  of  the  vertebral  articu- 
lations  causing   fixation  is  called  "  spondylitis   deformans." 

Treatment. — Rheumatic  gout  cannot  be  cured,  but  in  some 
cases  it  remains  stationary  for  many  years.  Treat  the  anemia 
by  iron,  arsenic,  good  food,  and  fresh  air.     Debihty  is  met  by 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    429 

strychnin.  Hot  baths  of  mineral  water  do  good.  Massage 
retards  the  progress  of  the  case,  reheves  the  pain,  aids  in 
the  absorption  of  effusion,  and  delays  fixation.  During  an 
acute  exacerbation  the  joint  should  be  put  at  rest  for  a  day 
or  two,  and  there  should  be  used  lead-water  and  laudanum, 
cold  water,  or  tincture  of  arnica.  Douches  and  hot  baths 
improv^e  these  cases,  but  electricity  is  entirely  useless.  Put- 
ting the  affected  joint  in  a  special  apparatus  and  subjecting 
it  to  a  high  degree  of  heat  improves  the  condition.  Counter- 
irritants  do  no  good.  The  patient  is  unfortunately  liable  to 
develop  the  opium-habit.  If  dropsy  of  a  joint  arises,  try 
compression  with  a  Martin  bandage,  and,  if  this  fails,  aspi- 
rate and  inject  diluted  carbolic  acid.  Patients  with  rheu- 
matic gout  do  best  in  a  warm,  dry  climate.  Cod-liver  oil 
does  good,  as  it  improves  nutrition  and  hence  retards  the 
progress  of  the  disease.  Do  not  be  tempted  to  immobilize 
the  joints  beyond  a  day  or  two :  fixation  only  hastens 
ankylosis. 

Charcot's  Disease  (Tabetic  Arthropathy  ;  Charcot's  Joint ; 
Neuropathic  Arthritis). — This  condition  is  an  osteo-arthritis 
due  to  trophic  disturbance,  arising  in  a  sufferer  from  loco- 
motor ataxia,  and  is  anatomically  identical  with  rheumatic 
gout.  The  knee  is  most  apt  to  be  attacked.  The  disease 
begins  acutely,  often  as  a  sudden  effusion,  which  after  a  time 
disappears.  Pain  is  slight  or  is  absent,  there  is  no  consti- 
tutional involvement,  and  the  condition  is  unconnected  with 
injury.  The  bones  and  cartilages  are  rapidly  destroyed; 
fracture  is  apt  to  occur;  the  joint  creaks  and  grates;  the 
softening  and  relaxation  of  ligaments  permit  an  extensive 
range  of  movement ;  great  deformity  ensues  ;  dislocation  is 
apt  to  occur ;  muscular  atrophy  is  decided  ;  and  pus  occa- 
sionally, though  very  rarely,  forms. 

Treatment. — The  treatment  of  Charcot's  disease  consists 
in  the  wearing  of  an  apparatus  to  sustain  the  joint.  Resec- 
tion is  recommended  by  some,  but  most  surgeons  do  not 
advise  its  performance. 

Osteo-arthropathie  Hypertrophiante  Pneumique 
(Marie's  Disease). — A  condition  associated  with  and  pos- 
sibly springing  from  pulmonary  disease,  and  characterized 
by  enlargement  of  joints,  thickening  of  finger-ends,  and  the 
formation  of  a  dorsolumbar  kyphosis.  The  joints  are  pain- 
ful, the  skin  undergoes  pigmentation,  and  profuse  perspira- 
tion is  often  present.  The  head  entirely  escapes  in  this 
disease,  which  immunity  marks  a  distinction  from  acromeg- 
aly. 


430  MODERN  SURGERY. 

Hysterical  joint  (Brodie's  joint)  is  a  condition  mostly- 
encountered  in  young  women.  The  disease  occurs  in  the 
knee  and  the  hip,  and  often  follows  a  slight  injury  which 
acts  as  an  autosuggestion,  a  latent  hysteria  being  awakened 
into  action  and  localized,  though  severity  of  the  injury  does 
not  determine  the  severity  of  the  symptoms.  The  disease 
may  ensue  upon  an  arthritis  or  may  arise  without  apparent 
cause.  The  patient  resists  passive  motion  strenuously  and 
claims  that  it  causes  much  pain.  There  is  occasionally 
some  muscular  atrophy  from  want  of  use,  and  the  joint 
is  a  little  swollen.  The  skin  is  hyperesthetic,  and  a  light 
touch  causes  more  pain  than  does  deep  pressure.  The 
muscles  may  be  rigid.  The  joint  may  be  maintained  either 
in  flexion  or  in  extension,  but  it  is  rarely  in  the  exact  degree 
of  flexion  assumed  for  ease  in  a  true  joint-inflammation,  and 
the  position  is  apt  to  be  changed  from  day  to  day  or  from 
hour  to  hour.  The  skin  is  usually  cool,  but  may  be  hot, 
and  a  periodically  developed  heat  may  be  observed,  espe- 
cially at  night,  accompanied  apparently  by  much  pain.  The 
pain  in  some  cases  is  a  neuralgia,  but  in  most  cases  is  a  pain- 
hallucination.  In  some  rare  cases  organic  disease  arises  in 
a  hysterical  joint. 

Hysterical  phenomena  are  seldom  isolated,  but  are  asso- 
ciated with  certain  stigmata  which  may  be  latent.  These 
stigmata  are  concentric  contraction  of  the  visual  fields, 
pharyngeal  anesthesia,  convulsions,  hysterogenic  zones, 
globus  hystericus,  clavus  hystericus,  zones  of  anesthesia, 
especially  hemianesthesia,  and  hyperesthetic  areas.  Such 
patients  are  predisposed  by  inheritance,  and  have  previously, 
as  a  rule,  had  nervous  troubles.  Hysterical  phenomena,  be 
it  remembered,  lack  regularity  of  evolution,  and  are  pro- 
duced, altered,  or  abolished  by  mental  influences  and  physi- 
cal sensations  which  are  without  effect  in  causing,  modifying, 
or  curing  organic  disease.  The  general  health,  as  a  rule,  is 
good,  but  neurasthenia  may  coexist.  In  examining  these 
patients  the  observer  will  note  that  the  symptoms  disappear 
when  the  attention  is  diverted ;  that  they  are  out  of  all 
proportion  to  the  local  evidences  of  the  disease ;  that  there 
is  no  evidence  of  joint-destruction  ;  and  that  light  touching 
causes  more  pain  than  does  firm  pressure.  If  the  patient  is 
anesthetized,  perfect  joint-mobility  will  be  found. 

Treatmc7it. — The  treatment  in  hysterical  joints  comprises 
attention  to  the  general  health,  the  employment  of  nourish- 
ing and  easily  digested  food,  the  prevention  of  constipation, 
and  the  administration  of  tonics  if  they  are  needed.     The 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    43 1 

surgeon  must  dominate  his  patient's  mind  and  make  her 
reahze  that  he  is  master  of  the  case.  He  is  to  be  an  inex- 
orable but  just  ruler — never  a  brutal  or  a  cruel  one.  If 
possible,  send  the  patient  away  from  the  sympathies  of  her 
home  and  let  her  have  the  rest-treatment  of  Weir  Mitchell. 
Local  remedies  applied  to  the  joint  do  harm,  as  a  rule,  by 
concentrating  afresh  the  patient's  attention  upon  the  articula- 
tion, although  the  hot  iron  sometimes  does  good.  Sugges- 
tion in  the  hypnotic  state  may  be  tried.  The  use  of  morphin 
should  be  avoided  as  being  the  worst  of  enemies.  Never 
immobilize  the  joint,  and  always  use  massage,  passive 
motions,  and  frictions. 

Neuralgia  of  the  joints  as  an  independent,  isolated 
affection  is  extremely  rare,  though  as  a  complication  of 
other  diseases  it  is  by  no  means  uncommon.  The  neuralgia 
is  more  often  outside  of  the  joints  than  in  them,  and  is  espe- 
cially frequent  in  the  knee  and  the  ankle.  Joint-neuralgia 
may  arise  in  any  person,  but  it  is  more  commonly  present 
in  young  neurotic  females.  The  pain  may  be  persistent,  or 
it  may  occur  in  periodic  storms,  and  it  is  often  associated  with 
neuralgia  in  other  parts.  The  pain  may  be  dull  and  aching, 
but  it  is  more  often  sharp  and  shooting.  Joint-neuralgia  is 
associated  with  tenderness  on  pressure,  soreness  on  motion, 
often  with  transitory  swelling  without  redness,  and  some- 
times with  numbness  of  the  extremity.  The  diagnosis 
depends  on  the  temperament  of  the  patient,  the  sudden 
onset  of  the  pain,  the  absence  of  constitutional  symptoms, 
and  the  free  mobility  of  the  joint,  especially  under  ether. 
Articular  neuralgia  may  depend  upon  disease  or  injury  of 
the  central  nervous  system,  upon  malaria,  syphilis,  neuras- 
thenia, rheumatism,  gout,  hysteria,  and  neuritis,  and  may  be 
due  to  reflected  irritation,  especially  from  the  ovaries,  the 
womb,  and  the  rectum. 

Treatment. — The  treatment  to  be  observed  in  joint-neu- 
ralgia is  to  maintain  the  general  health ;  examine  for  a 
possible  exciting  cause,  and,  if  found,  remove  it ;  give  a  long 
course  of  iron,  quinin,  and  strychnin  or  of  arsenic.  In  rheu- 
matic or  gouty  subjects  give  suitable  drugs  and  insist  upon 
proper  diet.  During  the  attack  use  phenacetin.  Morphin 
must  occasionally  be  used  in  severe  cases,  but  be  careful  of 
it,  and  never  tell  the  patients  they  are  taking  it,  as  there  is  a 
possibility  of  their  forming  the  opium-habit.  Locally,  employ 
frictions,  ointment  of  aconite,  heat,  and  keep  upon  the  part 
a  piece  of  flannel  soaked  in  a  mixture  of  soap-liniment, 
laudanum,  and  chloroform  (Gross).     Never  let  a  joint  stiffen  ; 


432  MODERN  SURGERY. 

any  tendency  to  do  so  should  be  met  by  daily  massage^ 
frictions,  passive  motion,  and  hot  and  cold  douches.  In 
some  rare  cases  nerve-stretching  or  neurectomy  becomes 
necessary. 

Articular  Wounds  and  Injuries.  —  A  penetrating- 
wound  is  very  serious,  and  it  may  be  due  to  compound 
fracture,  to  compound  dislocation,  to  gunshot-wounds,  or 
to  stabs.  If  a  bursa  near  a  joint  be  injured,  secondary 
penetration  may  occur  as  a  result  of  suppuration.  In  a 
penetrating  wound,  besides  pain,  hemorrhage,  and  swell- 
ing, there  is  a  flow  of  synovial  fluid.  A  small  amount  of 
synovia  flows  from  an  injured  bursa,  a  large  amount  from 
an  open  joint. 

Treatment. — If  a  joint  is  opened  aseptically  (as  when  in- 
cised by  the  surgeon),  it  gets  well  nicely  under  rest  and  anti- 
sepsis. If  a  joint  is  opened  by  a  septic  body,  suppurative 
arthritis  is  apt  to  arise,  and  the  indications  are  to  irrigate, 
drain,  dress  antiseptically,  and  secure  rest.  Normal  salt 
solution  is  the  best  agent  for  irrigation,  as  it  does  not  injure 
joint-endothelium.  Active  antiseptics  are  apt  to  lessen  tissue- 
resistance  and  thus  favor  infection.  In  gunshot-wounds,  if 
antisepsis  is  not  employed,  suppuration  is  inevitable ;  hence 
military  surgeons,  as  a  rule,  have  advocated  amputation  or 
excision  in  gunshot-splinterings  of  large  joints.  In  these 
injuries  the  wound  is  enlarged,  the  finger  is  introduced  to 
discover  and  remove  foreign  bodies,  through-and-through 
drainage  is  secured,  a  tube  is  inserted,  the  joint  is  irrigated, 
antiseptic  dressings  are  applied,  and  the  extremity  is  placed 
upon  a  splint.  Very  severe  cases  demand  resection  or  even 
amputation.  Ankylosis  more  or  less  complete  follows  a 
gunshot-wound  of  a  joint.  If  the  joint  suppurates,  the 
drainage  must  be  made  more  free,  sinuses  must  be  slit  up 
and  packed,  sloughs  must  be  cut  away,  dead  bone  must  be 
gouged  out,  and  the  patient  must  be  placed  upon  a  stimu- 
lant and  tonic  plan  of  treatment. 

Sprains. — A  sprain  is  a  joint-wrench  due  to  a  sudden  twist 
or  traction,  the  ligaments  being  pulled  upon  or  lacerated  and 
the  surrounding  parts  being  more  or  less  damaged.  A  sprain 
is  often  a  self-reduced  dislocation  (Douglas  Graham).  The 
joints  most  liable  to  sprains  are  the  knee,  the  elbow,  and  the 
ankle.  The  smaller  joints  are  also  often  sprained,  but  the 
ball-and-socket  joints  are  infrequently  sprained,  their  normal 
range  of  free  movement  saving  them ;  they  do  occasionally 
suffer  severely,  however,  as  a  result  of  abduction.  In  a  bad 
sprain  the  ligaments  are  torn  ;  the  synovial  membrane  is  con- 


DISEASES  AND   INJURIES   OF  RONES  AND  JOINTS.    433 

tused  or  crushed  ;  cartilages  are  loosened  or  separated  ;  hem- 
orrhage takes  place  into  and  about  the  joint ;  muscles  and 
tendons  are  stretched,  displaced,  or  lacerated ;  vessels  and 
nerves  are  damaged  ;  the  skin  is  often  contused ;  and  por- 
tions of  bone  or  cartilage  may  be  detached  from  their  proper 
habitat,  though  still  adhering  to  a  ligament  or  tendon  (sprain- 
fractures).  Sprains  are  commonest  in  young  persons  and  in 
adults  with  weak  muscles.  They  happen  from  sudden  twists 
and  movements  when  the  muscles  are  relaxed.  A  large  part 
of  the  support  of  joints  comes  from  muscles,  and  when 
they  are  suddenly  caught  unawares  they  do  not  support  the 
joint  and  a  sprain  results.  A  joint  once  sprained  is  very 
liable  to  a  repetition  of  the  damage  from  slight  force.  Sprains 
are  common  in  a  limb  wath  weak  muscles,  in  a  deformed  ex- 
tremity in  which  the  muscles  act  in  unnatural  lines,  and  in  a 
joint  with  relaxed  ligaments. 

Symptoms. — The  symptoms  manifested  in  sprains  are  as 
follows  :  severe  pain  in  the  joint,  accompanied  by  a  weakness. 
Nausea,  often  vomiting,  and  sometimes  syncope.  Impair- 
ment or  loss  of  motion  is  present.  This  condition  is  suc- 
ceeded by  a  season  of  relief  from  pain  while  at  rest,  numb- 
ness being  complained  of,  and  pain  on  motion  being  severe. 
Ver>'  soon  swelling  begins  if  hemorrhage  is  severe.  In  any 
case  swelling  begins  in  a  few  hours.  Movement  of  the  joint 
becomes  difficult  or  impossible  ;  the  tear  in  the  ligament  may 
be  distinctly  felt ;  pain  and  tenderness  become  intense  ;  joint- 
crepitus  will  be  detected ;  and  in  a  day  or  two  discoloration 
becomes  marked.  ]\Ioullin  and  others  have  pointed  out  that 
when  a  muscle  is  strained  the  skin  above  it  becomes  sensitive, 
especially  at  tendinous  insertions  over  joints.  As  muscles 
are  invariably  strained  when  a  joint  is  sprained,  there  is  in- 
variably some  cutaneous  tenderness.  There  is  always  ten- 
derness over  a  sprained  joint  due  to  capsular  injury,  bands  of 
adhesions,  etc.  Tenderness  is  apt  to  arise  at  certain  reason- 
ably fixed  points  :  in  a  hip-joint  injur}'  it  is  found  behind  the 
great  trochanter,  in  a  knee-joint  injur}'  by  the  side  of  the 
patella,  in  an  ankle-joint  injury  to  the  inner  side  of  the 
external  malleolus  (Culp).  When  the  ligaments  of  the 
back  are  sprained  the  back  muscles  are  rigid,  the  skin  is 
often  sensitive,  pain  may  be  awakened  by  pressure  or  by 
certain  movements,  but  there  is  no  sign  of  cord  injur}-. 

Diagnosis  and  Prognosis. — Sprain-fractures  can  be  diag- 
nosticated with  certainty  only  by  the  x-rays.  In  the  diag- 
nosis of  a  sprain  fracture  and  dislocation  must  be  consid- 
ered.    In  fracture,  crepitus  and  mobilit}'  exist ;  in  dislocation^ 

2S 


434  MODERN  SURGERY. 

rigidity.  The  diagnosis  should  be  made  by  a  consideration 
■of  the  joint  involved,  of  the  age,  of  the  nature  of  the  force, 
by  the  length  of  the  limb,  by  the  fact  that  the  patient  could 
use  the  joint  for  at  least  a  short  time  after  the  accident,  and 
by  the  local  feel  and  movements  of  the  part.  In  some  cases 
examine  under  ether,  in  some  apply  the  X-rays.  The  prog- 
nosis depends  on  the  size  of  the  joint,  on  the  extent  of  lacer- 
ation, and  on  the  amount  of  intra-articular  hemorrhage. 
The  danger  is  ankylosis. 

Treatment. — The  first  indication  is  to  arrest  hemorrhage 
and  Hmit  inflammation.  For  the  first  few  hours  apply  press- 
ure and  an  ice-bag.  Wrap  the  joint  in  absorbent  cotton 
wet  with  iced  water,  apply  a  wet  gauze  bandage,  and  put  on 
an  ice-bag.  In  a  mild  sprain  use  lead-water  and  laudanum 
or  apply  at  once  a  silicate  dressing.  In  a  severe  sprain  place 
the  extremity  upon  a  splint  and  to  the  joint  apply  flannel 
kept  wet  with  lead-water  and  laudanum,  iced  water,  tincture 
of  arnica,  alcohol  and  water,  or  a  solution  of  chlorid  of 
ammonium.  The  ice-bag  should  from  time  to  time  be  laid 
upon  the  flannel  for  periods  of  twenty  or  thirty  minutes. 
•Leeches  around  the  joint  do  good.  Constitutionally,  em- 
ploy the  remedies  for  inflammation  (page  60).  Morphin  or 
"Dover's  powder  is  given  for  the  pain.  Judicious  bandaging 
limits  the  swelHng. 

After  a  day  or  two,  if  the  symptoms  continue  or  if  they 
grow  worse,  use  hot  fomentations,  hot  lead-water  and  lauda- 
num, the  hot-water  bag,  plunge  the  extremity  frequently  in 
very  hot  water,  or  apply  heat  by  Leiter's  tubes.  When  the 
acute  symptoms  begin  to  subside,  rub  stimulating  liniments 
upon  the  joint  once  or  twice  a  day  and  employ  firm  com- 
pression by  means  of  a  bandage  of  flannel  or  rubber.  Fric- 
tions should  be  made  from  the  periphery  toward  the  body. 
Many  cases  do  well  at  this  stage  under  the  local  use  of 
ichthyol  and  lanolin  (50  per  cent.),  tincture  of  iodin,  or  blue 
ointment.  Later  in  the  case  use  hot  and  cold  douches, 
massage,  frictions,  passive  motion,  and  the  bandage.  Van 
Arsdale  treats  these  cases  by  massage  almost  from  the  start. 
Gibney  treats  sprains  by  strapping  with  adhesive  plaster. 
Passive  motion  is  begun  a  day  or  so  after  swelling  ceases. 
If  massage  causes  the  swelling  to  return,  abandon  it  for  sev- 
eral days  and  then  try  it  again.  Blisters  are  used  when  tender 
■spots  persist  and  stiffness  is  manifest.  If  stiffness  becomes 
marked,  move  the  joint  forcibly.  Give  iodid  of  potassium, 
use  tonics  internally,  and  insist  on  open-air  exercise.  If  the 
person   is    gouty  or    rheumatic,  use   appropriate   remedies. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    435 

Many  sprains  may  be  put  up  in  an  immoveable  dressing  the  first 
day  or  two  after  the  accident.  If  the  joint  contains  much  blood, 
aspiration  should  be  practised  before  the  dressing  is  applied. 

Ankylosis. — When  a  joint-inflammation  eventuates  in 
the  formation  of  new  tissue  in  and  about  the  joint  contraction 
of  this  tissue  limits  or  destroys  joint-mobility,  producing  the 
condition  known  as  "  ankylosis."  Ankylosis  may  be  com- 
plete (bony)  or  incomplete  (fibrous) ;  it  may  arise  from  con- 
tractures in  the  joint  (true  or  intra-articular  ankylosis)  or 
from  contractures  in  the  structures  external  to  the  joint  (false 
or  extra-articular  ankylosis). 

True  or  intra-articular  ankylosis  may  arise  from  any 
cause  which  produces  joint-inflammation  with  formation  of 
new  tissue,  and  may  be  due  to  wounds,  contusions,  sprains, 
dislocations,  fractures  in  or  near  a  joint,  movable  bodies  in  a 
joint,  tubercle,  gout,  rheumatism,  or  syphilis.  Want  of  use 
of  the  joints  causes  partial  ankylosis,  though  this  has  been 
denied.  Ankylosis  is  more  apt  to  take  place  in  a  hinge- 
joint  than  in  a  ball-and-socket  joint.  In  ankylosis  from  a 
general  cause  (as  rheumatic  gout)  many  joints  are  apt  to 
suffer.  Ankylosis  may  be  due  to  fibrous  tissue,  and  is  then 
usually  partial ;  it  may  be  due  to  chondrification  of  fibrous 
tissue,  and  is  then  incomplete ;  it  may  be  due  to  ossification 
of  fibrous  tissue,  and  is  then  complete,  the  joint  being 
entirely  immobile  (osseous  or  bony  ankylosis).  The  entire 
joint  may  be  converted  into  bone.  Only  one  small  joint- 
surface  may  contain  adhesions  (limited  adhesion),  or  the 
entire  joint-surface  may  be  bound  up  in  them  (diffused  ad- 
hesion). 

Fibrous  ankylosis  follows  aseptic  inflammations ;  bony 
ankylosis  is  apt  to  follow  infections.  Though  slight  motion 
is  usually  possible  in  fibrous  ankylosis,  in  some  cases  it  may 
be  impossible.  A  joint  immovable  from  fibrous  ankylosis  is 
distinguished  from  a  joint  immovable  from  bony  ankylosis 
by  the  fact  that  in  the  former  attempts  at  motion  are  pro- 
ductive of  pain,  and  subsequently  of  inflammation.  The 
incapacity  resulting  from  ankylosis  is  due,  first,  to  the  im- 
pairment or  destruction  of  joint-function,  and,  secondly,  to 
the  fixation  at  an  inconvenient  angle  (a  fixed  flexed  knee  is 
worse  than  a  fixed  extended  knee ;  a  fixed  extended  elbow 
is  worse  than  a  fixed  partly  flexed  elbow). 

Treatment. — The  effort  should  always  be  made  to  prevent 
an  ankylosis  by  treating  carefully  any  joint-inflammation  and 
by  beginning  passive  motion  at  the  earliest  safe  period.  To 
limit  inflammation  is  to  prevent  ankylosis.     Many  cases  of 


436  MODERN  SURGERY. 

fibrous  ankylosis  are  improved  by  passive  movements,  mas- 
sage, frictions,  stimulating  liniments,  inunctions  of  ichthyol 
or  mercurial  ointment,  hot  and  cold  douches,  hot-air 
baths,  and  electricity.  Some  cases  may  be  straightened 
out  slowly  by  screw-splints  or  by  weights  and  pulleys. 
Fibrous  ankylosis  of  the  elbow  is  best  treated  by  using  the 
joint.  Fibrous  ankylosis  is  often  corrected  by  forcible 
straightening.  If  the  tendons  are  much  contracted,  tenot- 
omy should  be  performed  two  or  three  days  before  forcible 
straightening  is  attempted.  In  order  to  straighten,  always 
give  ether.  Suppose  a  case  of  ankylosis  of  the  knee :  put 
the  patient  upon  his  back,  bring  the  leg  over  the  end  of 
the  operating-table,  grasp  the  ankle  with  one  hand  and  the 
lower  portion  of  the  leg  with  the  other  hand,  and  make 
strong,  steady  movements  of  flexion  and  extension  until  the 
limb  can  be  straightened.  The  adhesions  will  be  felt  to 
break,  the  snapping  often  being  audible.  At  once  apply  a 
plaster-of- Paris  dressing,  and  keep  the  limb  immobile  for  two 
weeks.  This  procedure  is  not  free  from  danger.  Vessels  may 
be  ruptured,  nerves  may  be  torn,  skin  and  fascia  may  be 
lacerated,  suppuration  may  ensue  from  the  admission  into  the 
joint  of  encapsuled  cocci,  or  of  organisms  in  the  blood  which 
find  in  this  area  a  point  of  least  resistance.  Because  of  the 
danger  of  opening  up  depots  of  encapsuled  bacilli  and  cocci, 
do  not  forcibly  break  up  an  ankylosis  that  results  from  a 
tubercular  or  a  septic  arthritis,  but  use  gradual  extension  by 
weights  or  by  screw-splints.  Ankylosis  of  the  knee  follow- 
ing fracture  of  the  patella  is  almost  sure  to  recur  after 
forcible  breaking  up.  The  best  treatment  for  knee-ankylosis 
is  use  of  the  joint.  In  bony  ankylosis  of  any  joint  other  than 
the  elbow-joint  do  nothing  if  the  joint  is  in  a  useful  position. 
If  the  joint  is  firmly  fixed  in  an  unfortunate  position,  resort 
to  excision  or  an  osteotomy.  In  the  elbow  excision  should 
be  performed,  no  matter  what  the  position,  in  the  hope  of 
obtaining  a  movable  joint.  In  ankylosis  of  the  jaw  surgeons 
are  apt  to  try  to  remedy  the  condition  by  wedging  the  jaws 
apart  with  a  mouth-gag,  and  afterward  inserting  boxwood 
plugs  at  frequent  intervals.  This  method  is  invariably  a  fail- 
ure.^ Esmarch's  operation  is  sometimes  curative  (removal 
of  a  wedge-shaped  piece  of  bone).  Some  operators  excise 
the  condyle  and  a  portion  of  the  neck.  Swain  advocates 
sawing  the  bone  at  the  angle. 

False    or   Extra-articular   Ankylosis. — In    this    disease 
the  joint  is  intact,  but  the  contractures  are  in  surrounding 

1  Swain,  in  Lancet,  1894,  vol.  ii.,  p.  187. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    437 

parts.  The  causes  are  muscular,  fascial,  and  tendinous  con- 
tractures, cicatrices  (especially  from  burns),  deposits  of  bone, 
muscular  paralysis,  tumors,  and  aneurysm.  Contractions  of 
muscles  or  tendons  may  be  due  to  gout,  rheumatism,  injury, 
thecitis,  fractures,  and  dislocations.  False  ankylosis  is  seen 
in  club-foot  and  in  Dupuytren's  contraction. 

Treatment. — The  treatment  of  false  ankylosis  depends 
upon  the  cause.  Recently  contracted  muscles  or  tendons 
require  motions,  massage,  frictions  with  stimulating  lini- 
ments, and  hot  and  cold  douches.  Old  contractions  require 
division.  Whenever  possible,  excise  a  cicatrix  that  causes 
false  ankylosis,  and  fill  the  gap  with  good  tissue.  Bony 
deposits  are  gouged  away  and  tumors  are  removed.  Con- 
tractures in  cases  of  paralysis  require  electricity,  passive 
motion,  frictions  with  stimulating  liniments,  the  hot-air 
bath,  and  general  treatment. 

l/oose  Bodies  in  Joints  (Floating  Cartilages). — The 
knee  is  the  joint  oftenest  affected.  These  bodies  may  be  free, 
may  have  a  stalk  or  pedicle,  may  move  about  and  occasion- 
ally block  the  joint,  or  may  lie  quietly  in  a  joint-recess  or 
diverticulum.  They  may  be  single  or  multiple,  flat  or  ovoid, 
smooth  or  irregular,  as  small  as  peas  or  as  large  as  plums, 
and  may  be  composed  of  fibrous  tissue,  of  bone,  or  of  carti- 
lage. There  are  numerous  different  modes  of  origin  of  these 
bodies,  many  being  "  detached  ecchondroses  or  pieces  of 
hyaline  cartilage  hanging  by  narrow  pedicles "  (J.  Bland 
Sutton),  and  they  result  from  enlargement  and  chondrifica- 
tion  of  the  villi  of  the  synovial  membrane.  Some  loose 
bodies  are  broken-off  osteophytes  ;  some  arise  from  blood- 
clots  ;  some  by  projection  or  herniation  of  the  synovial 
membrane,  which  protrusion  is  broken  ofl";  others  are  de- 
tached fringes  of  tubercular  synovial  membrane.  Trauma- 
tism is  usually  an  exciting  cause.  Loose  cartilages  are  com- 
monest in  adult  men. 

Symptoms. — Many  small  bodies  give  rise  to  no  symptoms 
other  than  those  of  synovitis.  A  large  body  produces  pain 
and  interferes  with  joint-function.  The  joint  is  weak  and 
a  little  swollen,  and  the  patient  can  feel  the  body  and  often 
can  push  it  into  a  superficial  area  of  the  joint,  where  it  may 
be  felt  by  the  surgeon.  From  time  to  time  the  body  may 
get  caught,  thus  suddenly  locking  the  joint  and  producing 
intense  and  sickening  pain,  extension  and  fle.xion  being  im- 
possible until  the  body  slips  out.  This  accident  is  followed 
by  inflammation  and  effusion. 

Treatment. — To  relieve  locking,  employ  forced  flexion  and 


438  MODERN  SURGERY. 

sudden  extension.  Cure  can  be  obtained  only  by  operation. 
Asepticize  with  the  utmost  care.  Let  the  patient  bring  the 
foreign  body  to  a  point  where  it  can  be  felt ;  the  surgeon 
then  fixes  it  with  a  pin  or  holds  it  with  the  fingers,  ether 
being  given  or  cocain  being  used.  The  joint  is  now  opened, 
the  foreign  body  extracted,  and  an  exploration  made  to 
see  that  no  other  bodies  are  present.  The  wound  is  now  ■ 
stitched  and  the  leg  is  placed  upon  a  splint.  Asepsis  must 
be  most  rigid.  The  operation  does  not  cure  the  causative 
lesion,  and  these  bodies  are  apt  to  form  again. 

4.  Luxations  or  Dislocations. 

A  dislocation  is  the  persistent  separation  from  each  other, 
partially  or  completely,  of  two  articular  surfaces.  A  self- 
reduced  dislocation  is  called  a  sprain.  There  are  three  forms 
of  dislocation:  (i)  traumatic;  (2)  spontaneous  or  pathologi- 
cal ;  (3)  congenital. 

I.  Traumatic  dislocations  are  due  to  injury.  They 
are  divided  into — coinpletc  dislocation,  in  which  the  two 
articular  surfaces  are  entirely  separated  and  the  ligaments  are 
torn ;  incomplete  or  partial  dislocation,  in  which  the  two 
articular  surfaces  are  not  completely  separated  and  the  liga- 
ments are  rarely  lacerated ;  simple  dislocation,  in  which  the 
articular  surfaces  are  not  brought  into  contact  with  the  ex- 
ternal air;  compound  dislocation,  in  which  the  external  air 
has  access  to  the  articular  surfaces  ;  complicated  dislocation, 
in  which,  besides  the  dislocation,  there  is  a  fracture,  exten- 
sive damage  of  the  soft  parts,  an  opening  admitting  air  to  the 
soft  parts,  or  damage  of  a  nerve  or  blood-vessel ;  primitive 
dislocation,  in  which  the  bones  remain  as  originally  displaced ; 
secondary  dislocation,  in  which  the  bone  assumes  a  new 
position  :  for  instance,  a  subglenoid  luxation  of  the  humerus 
is  primary,  and  it  may  become  secondarily  a  subcoracoid 
luxation  because  of  muscular  contraction  or  attempts  at 
reduction ;  recent  dislocation,  in  which  the  displaced  bone  is 
not  firmly  fastened  by  tissue-changes  in  its  new  situation, 
and  its  old  socket  is  not  obliterated  ;  old  dislocation,  in  which 
the  displaced  bone  is  firmly  fastened  by  tissue-changes  in  its 
new  habitat,  and  the  old  socket  is  to  a  great  extent  obliter- 
ated (whether  a  dislocation  is  old  or  new  depends  on  the 
state  of  the  parts  rather  than  on  the  time  which  has  elapsed 
since  the  accident) ;  double  dislocation,  in  which  correspond- 
ing bones  on  each  side  are  dislocated ;  single  dislocation,  in 
which  only  one  joint  is  dislocated  ;  unilateral  dislocation,  in 


DISEASES  AND   IXJURIES   OF  BONES  AND  JOINTS.    439 

which  one  articulation  of  one  bone  is  out  of  place ;  bilateral 
dislocation,  in  which  symmetrical  articulations  are  dislocated  ; 
and  relapsing  ox  habitual  dislocation,  which  recurs  constantly 
from  slight  force  because  of  relaxed  ligaments  or  lack  of 
complete  repair  after  the  ligamentous  rupture  of  a  first  dis- 
location. 

2.  Spontaneous,  Pathological,  or  Consecutive  Dis- 
locations.— Spontaneous  dislocation  arises  from  such  very 
slight  force  that  it  often  cannot  be  identified,  and  it  acts  on 
a  joint  rendered  lax  by  disease.  It  may  arise  in  the  course 
of  chronic  synovitis  and  during  tubercular  joint-disease.  In 
typhoid  fever  spontaneous  dislocation  is  not  uncommon. 
The  hip-joint  is  most  often  the  one  attacked.  The  dislo- 
cation follows  a  severe  joint-inflammation,  is  usually  upon 
the  dorsum  of  the  ilium,  and  is  frequently  not  noticed  until 
convalescence.  If  a  typhoid  dislocation  is  seen  early,  reduc- 
tion is  easily  effected,  but  if  seen  late  is  impossible.  The 
treatment  for  irreducible  typhoid  dislocation  is  the  same  as 
for  any  other  irreducible  dislocation.  In  Charcot's  joint 
{artJiropathie  des  ataxiqiies)  this  form  of  dislocation  con- 
stantly appears.  This  condition  comes  on  in  a  few  hours, 
during  the  progress  of  locomotor  ataxia,  and  is  without  ap- 
parent reason.  The  knee,  the  shoulder,  or  some  other  joint 
becomes  greatly  swollen,  fluid  gathers  in  large  amount,  the 
ligaments  relax,  the  joint  is  destroyed  and  becomes  exces- 
sively mobile,  but  there  is  no  pain,  no  fever,  and  no  sign  of 
inflammation  (p.  429).     In  Charcot's  joint  apply  a  support. 

3.  Congenital  Dislocations. — The  third  form,  or  con- 
genital dislocation,  is  due  to  a  congenital  joint-malformation 
which  renders  it  impossible  for  the  bone  to  maintain  a  nor- 
mal position,  or  is  due  to  external  violence  during  the  period 
of  uterine  gestation.  Congenital  dislocations  should  not  be 
confounded  with  dislocations  produced  during  delivery. 
The  hip  is  the  joint  most  often  involved.  The  shoulder 
suffers  occasionally.  Lannelongue  maintains  that  congenital 
dislocation  of  the  hip  is  due  to  atrophy  of  the  muscles  and 
of  the  acetabulum  following  spinal-cord  disease.  Verneuil 
thinks  the  dislocation  is  paralytic.  Broca  truly  says  that  in 
view  of  the  fact  that  the  head  of  the  bone  is  larger  than  the 
cavity  in  which  it  belongs  it  is  entirely  useless  to  attempt 
reduction  by  manipulation  or  extension.  Hoffa  and  Lorenz 
have  each  devised  an  operation  for  this  condition  (p.  503). 
Congenital  dislocation  of  the  shoulder  requires  incision,  pos- 
sibly excision,  or  the  paring  dow^n  of  the  head  to  fit  the 
glenoid  cavity  (Phelps). 


440  MODERN  SURGERY. 

Traumatic  Dislocations. — In  the  succeeding  pages 
the  traumatic  form  of  dislocations  will  be  particularly  con- 
sidered. 

The  causes  of  traumatic  dislocations  are  divided  into  pre- 
disposing and  exciting. 

Predisposing  causes  are  (i)  Age — dislocations  are  com- 
monest in  middle  life,  the  usual  lesion  of  the  young  being 
green-stick  fracture,  and  that  of  the  old  being  fracture. 
Dislocations  of  the  radius  are  not  uncommon  in  youth. 
(2)  Muscular  development — dislocations  being  commonest  in 
those  with  powerful  muscles.  (3)  Sex — males  being  more 
predisposed  than  females,  because  of  their  occupations  and 
muscular  strength.  (4)  Occupation  predisposes  as  a  cause 
according  as  it  demands  the  employment  of  muscular  force, 
as  in  the  carrying  of  burdens.  (5)  Nature  of  the  joint — 
ball-and-socket  joints  being  more  liable  to  luxation  than  are 
ginglymoid  joints,  because  of  their  wide  range  of  motion. 
(6)  Joint-disease  predisposes  by  relaxing  the  ligaments.  (7) 
Situation  of  the  Joint — some  joints  being  more  exposed  to 
injury  than  others. 

Exciting  causes  are  classified  into  (i)  external  violence 
and  (2)  muscular  action.  External  violence  may  be  direct, 
as  when  a  blow  upon  one  of  the  bones  forces  it  directly 
away  from  the  other ;  or  it  may  be  indirect,  as  when  a  blow 
at  a  distant  part  of  a  bone  transmits  force  to  its  end  and 
drives  the  bone  out  of  its  socket.  Muscidar  action  is  a 
cause  when  sudden  and  violent  muscular  contraction  occurs 
during  the  maintenance  of  a  position  of  the  joint  which  gives 
the  muscles  full  sway,  and  throws  the  head  of  the  bone 
against  the  weakest  part  of  its  retaining  ligaments. 

Patholog-ical  Conditions. — In  a  recent  complete  trau- 
matic dislocation  the  ligaments  are  damaged,  and  may 
perhaps  show  extensive  laceration,  or  may  show  only  a 
button-hole  laceration  through  which  a  bone  projects.  Ex- 
ternal force  produces  much  laceration  and  little  stretching 
of  the  ligaments ;  muscular  action  produces  little  laceration 
and  much  stretching  of  the  ligaments  (Mears).  In  some 
cases  of  dislocation  due  to  external  violence  the  structures 
about  the  joint  are  bruised  or  otherwise  damaged ;  the  old 
socket  is  filled  with  blood,  and  the  bone  in  its  new  situa- 
tion lies  in  a  bloody  area.  Large  vessels  and  nerves  are 
rarely  torn,  though  they  may  be  compressed. 

If  a  dislocation  is  not  soon  reduced,  inflammation  arises 
in  the  old  joint  and  about  the  displaced  bone,  and  the  whole 
area   is    glued   together,  first   by  coagulated   exudate,  and 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    44 1 

finally  by  fibrous  tissue.  After  a  time,  in  ball-and-socket 
joints,  the  old  socket  fills  with  fibrous  tissue,  contracts, 
becomes  irregular,  and  may  even  be  obliterated ;  the  head 
of  the  dislocated  bone  alters  its  shape,  its  cartilage  is  de- 
stroyed or  converted  into  fibrous  tissue,  and  the  pressure 
of  the  head  of  the  bone  forms  a  hollow  in  its  new  situation, 
which  hollow  becomes  surrounded  by  fibrous  tissue  or  even 
by  bone.  A  new  joint  may  form,  the  surrounding  tissue 
becoming  a  compact  capsule,  and  a  bursa  forming  between 
the  head  of  the  bone  and  its  new  socket.  In  a  dislocated 
hinge-joint  the  ends  of  the  bone  alter  greatly  in  shape  and 
their  cartilage  is  converted  into  fibrous  tissue.  In  an  unre- 
duced dislocation  the  muscles  shorten  or  lengthen  or 
undergo  atrophy  or  fatty  degeneration,  as  the  case  may  be. 
An  unreduced  dislocation  of  a  ball-and-socket  joint  may 
give  a  fairly  movable  new  joint,  but  an  unreduced  disloca- 
tion of  a  hinge-joint  rarely  allows  of  much  motion. 

General  Symptoms  of  Traumatic  Dislocations. — In 
general,  traumatic  dislocations  are  indicated  (i)  by  pain  of 
a  sickening,  nauseating  character ;  (2)  by  rigidity  voluntary 
motion  is  impossible  except  to  a  slight  extent  in  the  direc- 
tion of  the  deformity.  (For  instance,  in  dislocation  of  the 
inferior  maxillar}^  the  jaw  can  be  opened  a  little  more,  but 
it  cannot  be  closed.  This  rigidity  brings  about  loss  of 
function.  When  the  surgeon  attempts  to  move  the  joint 
he  finds  it  very  rigid) ;  (3)  by  change  in  the  shape  of  the  Joint 
(as  flattening  of  the  shoulder  after  dislocation  of  the  hume- 
rus) ;  (4)  by  alteration  in  the  nnitnal  relations  of  bony  promi- 
nences about  a  Joint  (alteration  of  the  relation  between  the 
olecranon  and  humeral  condyles  in  dislocation  of  the  elbow 
backward) ;  (5)  by  feeling  the  displaced  bone  in  its  new 
situation ;  (6)  by  missing  the  head  of  the  bone  from  its 
proper  situation  ;  (7)  by  alteration  in  the  length  of  the  limb' 
(in  dislocation  of  the  femur  into  the  thyroid  foramen  the 
leg  is  lengthened,  but  in  dislocation  into  the  dorsum  of  the 
ilium  it  is  shortened) ;  and  (8)  by  alteration  in  the  axis  of 
the  bone  (in  dislocation  upon  the  dorsum  of  the  ilium  the 
axis  of  the  injured  thigh  would,  if  prolonged,  pass  through 
the  lower  third  of  the  sound  thigh) ;  (9)  by  seeing  the  dislo- 
cation with  a  fluoroscope  or  looking  at  a  skiagraph  of  it. 

Diagnosis  of  Traumatic  Dislocation. — A  dislocation 
may  be  mistaken  for  a  fracture.  In  dislocation  there  is 
rigidity,  in  fracture  there  is  preternatural  mobility ;  in  dislo- 
cation there  is  no  true  crepitus  (may  get  tendon-  or  joint- 
crepitus),  in  fracture  there  usually  is  crepitus  ;  in  dislocation 


442  MODERN  SURGERY. 

the  deformity  does  not  tend  to  recur  after  reduction,  in 
fracture  it  does  recur  after  extension  is  relaxed.  In  a  sprain 
the  movements  of  the  joint  are  only  limited,  not  abolished, 
by  an  almost  complete  rigidity.  The  change  which  a  sprain 
may  cause  in  the  shape  of  a  joint  is  due  to  effusion  or  to 
bleeding ;  there  is  no  alteration  in  the  relation  of  the  bony 
prominences  to  one  another ;  there  is  no  notable  alteration 
in  the  length  of  the  limb  (a  slight  increase  in  length  may 
arise  from  joint-effusion,  or  the  head  of  the  bone  may  sub- 
sequently be  absorbed,  and  thus  produce  shortening  after 
some  weeks) ;  there  is  no  alteration  in  the  axis  of  the  bone ; 
the  head  is  not  felt  in  a  new  position,  it  being  found  in  its 
normal  place.  Always  remember  that  a  fracture  may  exist 
with  a  dislocation.  In  any  doubtful  case — in  fact,  in  most 
cases — give  ether,  for  a  dislocation  should  be  reduced  while 
the  patient  is  anesthetized  (except  in  dislocation  of  the  jaw, 
of  the  fingers,  of  the  carpus,  etc.).  In  some  cases  swelling 
renders  the  diagnosis  difficult  or  impossible.  Always  com- 
pare the  injured  joint  with  the  corresponding  joint  of  the 
sound  side.  The  X-rays  constitute  a  valuable  aid  to  diag- 
nosis. 

Treatment  of  Traumatic  Dislocations. — Recent  Simple 
Dislocations. — Reduce  simple  dislocations  under  ether,  as  a 
rule.  Try  manipulation,  a  procedure  in  which  it  is  sought 
to  make  the  bone  retrace  its  own  pathway.  If  this  proced- 
ure fails,  employ  extension  and  counter-extension.  If  con- 
siderable force  is  needed,  an  assistant  makes  counter-exten- 
sion, and  the  surgeon  fastens  to  the  extremity  a  clove-hitch 
which  he  ties  about  his  waist,  and  thus  secures  powerful 
extension.  Counter-extension  may  be  obtained  by  bands, 
or,  in  some  instances,  by  the  foot  of  the  surgeon.  The 
clove-hitch  is  used  because  it  will  not  tighten  by  traction, 
■  as  a  tightening  band  would  lacerate  the  soft  parts  (Fig.  112). 
If  great  power  is  needed,  compound  pulleys  may  be  em- 
ployed, such  as  the  Jarvis  adjuster  or  some  similar  appli- 
ance, but  at  the  present  day  pulleys  are  rarely  used 
(see  page  444).  If  these  means  fail,  cut  down  upon  the 
bone  and  restore  it  to  position ;  operation  is  much  safer 
than  is  the  application  of  great  force.  After  reducing  a 
dislocation,  immobilize  the  joint  for  a  time  (time  varies 
with  different  joints),  and  for  the  first  few  days  combat  swell- 
ing and  inflammation  with  evaporating  lotions.  If  there 
exists  a  fracture  of  the  dislocated  bone,  apply  splints  and 
then  try  to  reduce  by  manipulations,  grasping  the  limb  and 
the  splint  with  one  hand  below  and,  if  possible,  with  the 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    443 

Other  hand  above  the  seat  of  the  fracture.  In  some  cases 
with  fracture  reduction  can  be  much  aided  by  making  a 
small  incision,  screwing  a  gimlet  into  the  head  of  the  bone, 
and  using  this  tool  as  a  handle.  McBurney  incises,  drills 
a  hole  in  each  bone,  inserts  hooks  into  them,  and  pulls  the 
dislocated  bone  into  position  (Figs.  68,  69).  When  the  dislo- 
cation has  been  reduced  the  bone  fragments  are  wired.  Allis 
believes  that  a  dislocation  can  be  reduced  even  when  a  fract- 
ure exists.  It  is  possible  to  pull  the  dislocated  head  down 
to  the  joint,  because  a  portion  of  periosteum  and  possibly 
tendinous  material  and  muscle  still  hold  the  two  fragments 
as  a  strap  might  unite  two  sticks.  The  head  can  be  forced 
into  place  by  the  fingers  while  traction  is  being  made.  If 
the  fracture  is  near  the  joint  and  the  fragments  cannot  be 
fixed,  try  to  reduce  the  dislocation,  first  striving  to  press  the 
bone  into  place.  This  attempt  can  be  greatly  aided  by 
traction  upon  the  lower  fragment. 

Compound  Traumatic  Dislocations. — The  opening  in  the 
soft  parts  may  be  due  to  external  violence  or  to  projection 
of  a  bone.  Compound  dislocations  are  very  serious.  Hinge- 
joints  are  more  liable  to  these  injuries  than  are  ball-and- 
socket  joints.  Many  cases  require  excision  and  amputation  ; 
one  that  does  not  demand  excision  or  amputation  should  be 
treated  by  counter-opening,  by  careful  antisepsis,  by  drainage, 
and  by  immobilization,  ankylosis  generally  ensuing,  except 
sometimes  in  the  small  joints.  It  is  scarcely  ever  necessary 
to  cut  away  any  portion  of  the  protruding  bone  to  effect 
reduction.  If  a  joint  is  badly  splintered,  or  if  the  soft  parts 
are  extensively  damaged,  excise  or  amputate ;  if  the  main 
vessels  or  the  nerves  are  seriously  injured,  or  if  the  patient 
is  so  old  or  so  feeble  that  it  is  perilous  to  force  him  to  combat 
a  long  illness,  amputate. 

Old  Traumatic  Dislocations. — The  problem  always  pre- 
sented in  old  dislocation  is.  Shall  reduction  be  tried,  or 
shall  the  bones  be  left  alone  ?  Sir  Astley  Cooper  laid  down 
this  rule  :  "  Do  not  attempt  to  reduce  a  shoulder-dislocation 
after  three  months,  nor  a  hip-dislocation  after  two  months  ;" 
but  this  rule  was  laid  down  before  the  days  of  ether.  Do 
not  select  any  fixed  period  of  time  to  determine  what  action 
is  advisable.  In  dislocation  of  a  ball-and-socket  joint  con- 
siderable motion  may  become  possible  and  a  new  joint  may 
form.  If  movement  does  not  produce  pain,  a  useful  new 
joint  may  be  obtained  b\'  the  persistent  employment  of  active 
and  passive  movements ;  if  movement  of  the  limb  does 
produce  pain,  enough  motion  will  not  be  attempted  by  the 


y\/\/\  MODERN  SURGERY. 

patient  to  produce  a  useful  joint.  In  the  former  case  try  to 
obtain  a  useful  new  joint,  and  in  the  latter  case  try  to  reduce 
the  old  dislocation. 

In  trying  to  reduce  an  old  dislocation,  give  ether,  make 
movement  to  break  up  adhesions,  and  persist  in  making 
these  motions  until  the  head  of  the  bone  is  felt  to  move ; 
then  try  at  once  to  reduce  by  manipulation,  extension,  or 
the  pulleys,  not  waiting  for  two  days,  as  some  suggest.  If 
the  head  of  the  bone  cannot  be  made  to  move,  the  Dieffen- 
bach  plan  may  be  followed,  which  is  to  cut  the  tense 
restraining  bands  with  a  tenotome.  Always  remember  that 
dislocations  of  a  hinge-joint,  if  left  unreduced,  will  never 
eventuate  in  a  useful  artificial  joint.  Sir  Joseph  Lister,  being 
much  impressed  with  the  danger  inevitably  linked  with  for- 
cibly dragging  old  dislocations  into  place,  prefers  to  cut 
down  and  restore  the  bone,  employing,  of  course,  the  strict- 
est asepsis.  Many  surgeons  adhere  to  this  view.  In  some 
old  dislocations  excision  of  the  head  of  the  bone  is  the  proper 
operation. 

Special  Traumatic  Dislocations. — Lower  Jaw. — 
Without  fracture  the  lower  jaw  can  only  be  dislocated  for- 
ward. There  are  two  forms  of  dislocation — the  unilateral, 
which  is  rare,  and  the  bilateral,  which  is  common.  Disloca- 
tions of  the  jaw  are  commonest  in  women  and  during  middle 
life.  When  the  mouth  is  open  contraction  of  the  external 
pterygoid  may  pull  the  condyle  over  the  articular  eminence ; 
this  contraction  may  be  brought  about  by  yawning,  vomiting, 
scolding,  etc.  When  the  mouth  is  open  dislocation  of  the 
lower  jaw  may  be  caused  by  a  blow  upon  the  chin ;  it  may 
also  be  caused  by  forcing  the  mouth  more  widely  open  by 
pushing  a  bulky  body  between  the  teeth. 

Syinptoms  of  Lower-jatv  Dislocations. — In  the  bilateral 
form  the  mouth  is  open  and  fixed,  and  it  cannot  be  closed, 
though  it  can  be  opened  a  little  more.  The  condyles  are 
in  front  of  the  articular  eminences,  and  are  fixed  by  the 
action  of  the  masseters  and  internal  pterygoids,  the  coronoid 
processes  being  wedged  against  the  malar  bones.  The  lower 
jaw  is  advanced  in  front  of  the  upper  and  the  face  looks 
longer  than  natural.  The  lips  cannot  close,  the  saliva  over- 
flows, swallowing  and  speech  are  difficult,  there  is  a  depres- 
sion in  front  of  each  ear,  the  condyles  are  recognizable  in  their 
new  abodes,  the  coronoid  processes  are  detected  by  a  finger  in 
the  mouth,  and  the  masseters  and  temporals  stand  out  in  a 
state  of  rigidity.  Pain  may  be  severe  or  be  absent.  In  the 
unilateral  form  the  chin  goes  toward  the  sound  side,  and  the 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    445 

mouth  is  not  so  widely  open  as  in  the  bilateral  form,  neither 
is  the  jaw  so  fixed.  The  symptoms  are  similar  to  those  of 
a  bilateral  luxation,  but  are  not  so  pronounced.  The  hollow 
in  front  of  the  ear  and  the  condyle  in  an  abnormal  situation 
are  only  detected  upon  one  side.  In  an  unreduced  disloca- 
tion the  patient  may  after  a  time  establish  some  movement 
of  the  jaw,  but  the  power  of  mastication  will  always  be  im- 
paired seriously. 

Treatvicnt  of  Lo%vcr-jaw  Dislocations. — In  treating  dislo- 
cations of  the  lower  jaw  the  patient  is  placed  with  his  head 
against  the  back  of  a  chair  or  against  the  body  of  an  assist- 
ant. The  surgeon,  after  wrapping  up  his  thumbs  to  protect 
them  from  being  bitten,  stands  in  front  of  the  patient,  puts 
his  thumbs  upon  the  last  molar  teeth,  and  grasps  the  chin 
with  his  free  fingers.  He  now  presses  downward  and  back- 
ward on  the  jaw,  and  as  soon  as  the  condyle  is  loosened 
closes  the  jaw  over  the  thumbs  by  pushing  up  the  chin, 
using  his  thumbs  as  levers.  If  this  procedure  fails,  wedges 
should  be  put  between  the  molar  teeth  and  the  chin  should 
be  pushed  up  either  by  the  hands  or  by  a  tourniquet  whose 
band  is  round  the  head  and  chin.  In  a  unilateral  disloca- 
tion the  wedge  should  only  be  used  on  the  injured  side. 
In  difficult  cases  Sir  Astley  Cooper  pushed  a  round  wooden 
ruler  between  the  molar  teeth,  used  the  upper  teeth  as  a 
fulcrum,  and  raised  the  end  of  the  ruler  as  the  handle  of 
a  lever.  The  forceps  used  by  an  anesthetizer  may  depress 
the  condyle  from  its  point  of  fixation,  whereupon  the  chin 
may  be  pushed  up  and  back.  Nelaton's  plan  was  to 
put  the  thumbs  in  the  mouth  and  push  the  coronoid  pro- 
cesses backward.  In  an  old  dislocation  always  try  reduc- 
tion, at  least  up  to  a  period  of  six  or  seven  months.  After 
reduction  apply  a  Barton  bandage  for  over  two  weeks,  taking 
it  off  once  a  day,  and  begin  passive  motion  in  the  second 
week ;  discard  the  bandage  in  the  third  week.  Liquid  diet 
is  advisable  for  three  weeks  after  the  accident.  An  unre- 
ducible dislocation  requires  osteotomy  of  the  neck  of  the 
bone,  if  the  part  cannot  be  restored  after  incision. 

Dislocation  of  the  Clavicle. — Sternal  End. — There  are 
three  forms  of  dislocation  of  the  sternal  end  of  the  clavicle, 
namely:  (i)  forward;  (2)  backward;  and  (3)  upward. 

For-ward  Dislocation  of  the  Sternal  End  of  the  Clavicle. 
— The  causes  of  forward  dislocation  of  the  clavicle  are  blows, 
falls,  or  pulls  which  drive  or  draw  the  shoulder  backward. 

Symptoms  and  Treatment  of  Forn'ard  Dislocation  of  the 
Clavicle. — The  symptoms  manifest  in  dislocation  of  the  clavi- 


446  MODERN  SURGERY. 

cle  are — prominence  in  front  of  the  sternum;  the  acromion 
is  nearer  to  the  sternum  on  the  injured  than  on  the  sound 
side ;  the  clavicular  origin  of  the  sternocleidomastoid  is 
rigid ;  movement  is  difficult  and  painful.  To  treat  a  dislo- 
cation of  the  clavicle,  pull  the  shoulders  back  against  the 
knee  of  the  surgeon,  which  is  placed  between  the  scapulae. 
Dress  with  a  posterior  figure-of-8  bandage  (Fig.  271),  or  a 
Velpeau  bandage  (Fig.  273),  the  dressing  to  be  worn  for 
three  weeks.  After  removal  of  the  dressing  apply  a  tru3s, 
the  pad  of  which  is  put  over  the  head  of  the  clavicle,  and 
which  instrument  is  to  be  worn  for  a  month.  Dislocation 
of  the  clavicle  is  difficult  to  keep  reduced,  but  even  if  it 
becomes  fixed  in  deformity  the  motions  of  the  arm  will  not 
be  impaired  permanently.  It  can  be  reduced  and  fixed  by 
incision  and  wiring. 

Backward  dislocation  of  the  sternal  end  of  the  clavicle 
is  very  rare.  The  causes  are  direct  violence  and  indirect  force, 
such  as  falls  or  blows  which  drive  the  shoulder  forward  and 
inward. 

Symptoms  and  Treatment  of  Backzvard  Dislocation  of  the 
Clavicle. — The  symptoms  are — pain ;  loss  of  function  in  the 
arm ;  incHnation  of  head  toward  the  injured  side  ;  stiffiiess  of 
the  neck ;  the  shoulder  passes  forward  and  inward,  and  often 
falls  downward ;  a  depression  exists  over  the  sternoclavicular 
joint;  the  head  of  the  clavicle  cannot  be  felt,  or  is  found 
back  of  the  sternum.  The  displaced  clavicle  may  press  upon 
the  trachea,  the  esophagus,  or  the  great  vessels,  inducing 
dyspnea,  dysphagia,  obliteration  of  pulse  in  the  arm  of  the 
injured  side,  or  great  venous  congestion  of  the  head  (see 
Pick).  To  treat  a  backward  dislocation,  pull  the  shoulders 
backward  and  apply  a  posterior  figure-of-8  bandage  (Fig. 
271),  which  must  be  worn  for  three  weeks.  If  pressure- 
symptoms  are  urgent,  resect  the  displaced  head. 

Upward  dislocation  of  a  clavicle  is  very  rare.  The 
cause  is  indirect  force  which  carries  the  shoulder  downward, 
inward,  and  backward  (Smith). 

Symptoms  and  Treatment  of  Upward  Dislocation  of  the 
Sternal  End  of  the  Clavicle. — The  chief  symptom  is  impaired 
function  of  the  arm ;  the  shoulder  passes  downward  and 
inward,  the  clavicular  axis  is  altered,  and  the  displaced  head 
is  felt.  Dyspnea  may  or  may  not  exist.  To  treat  this  dis- 
location, put  a  pad  in  the  axilla  and  press  the  elbow  to  the 
side  in  order  to  throw  the  bone  outward,  and  tiy  to  push  the 
head  into  place.  Apply  a  Desault  bandage  (Fig.  276) 
and  place  a  firm  pad  over  the  sternoclavicular  joint.     The 


DISEASES  AXD   IXJURIES   OF  BONES  AND  JOINTS.   447 

deformity  is  apt  to  recur,  but  a  useful  limb  will  nevertheless 
be  obtained.     It  may  be  desirable  to  wire  the  bones  in  place. 

Dislocation  of  the  acromial  end  of  the  clavicle  is  almost 
alwa)'s  upward,  but  it  may  be  below  the  acromion.  The  cause 
is  violent  force,  which,  if  so  applied  to  the  scapula  as  to  drive 
the  shoulder  forward,  may  produce  a  dislocation  upward.  A 
dislocation  downward  is  due  to  blows  upon  the  upper  surface 
of  the  outer  end  of  the  clavicle. 

Symptoms  mid  Treatment. — The  symptoms  of  dislocation 
of  the  acromial  end  of  the  clavicle  are — prominence  of  the 
clavicle  upon  the  top  of  the  acromion ;  impaired  function  of 
the  arm  (it  cannot  be  lifted  over  the  head) ;  the  shoulder  falls 
downward  and  passes  inward ;  there  is  apparent  lengthening 
of  the  arm  ;  the  head  is  bent  toward  the  injured  side,  and  the 
clavicular  origin  of  the  trapezius  is  strongly  outlined  (Pick). 
In  dislocation  downward  both  the  acromion  and  the  coracoid 
are  very  prominent,  the  clavicular  axis  is  altered,  and  there 
is  depression  over  the  sternoclavicular  joint.  A  dislocation 
upward  is  reduced  by  pulling  the  shoulder  back  and  pushing 
the  bone  into  place.  The  old  method  was  to  apply  a 
Desault  bandage,  which  was  kept  on  for  three  weeks,  and 
more  or  less  deformity  was  looked  for  as  inevitable.     Stim- 


FiG.  109. — Rhoads's  apparatus  for  treating  dislocation  upward  of  the  acromial  end  of  the 

clavicle. 

son  dresses  with  adhesive  plaster.  The  author  has  recently 
seen  a  case  treated  by  the  apparatus  of  Thomas  Leidy 
Rhoads.     The  apparatus  completely  corrected  the  deformity, 


448  MODERN  SURGERY. 

and  the  patient  made  a  most  satisfactory  recovery.  The 
essential  element  of  Rhoads's  apparatus  is  a  trunk  strap 
applied  as  is  shown  in  Fig.  109.  Dislocation  downward  is 
reduced  and  treated  in  the  same  manner  as  dislocation 
upward. 

The  so-called  dislocation  of  the  low^er  angle  of  the 
scapula  is  not,  as  it  was  long  thought  to  be,  a  disloca- 
tion at  all.  The  lower  angle  and  vertebral  border  deviate 
from  the  chest.  This  condition  was  thought  to  be  due  to  the 
bone  slipping  from  under  the  latissimus  dorsi  muscle,  but  it 
is  now  known  to  be  due  to  paralysis  of  the  serratus  magnus 
muscle,  the  bone  being  acted  upon  by  the  trapezius,  pector- 
alis  minor,  levator  anguli  scapulae,  and  rhomboid  muscles. 
Examination  shows  that  the  scapula  will  not  rotate  normally 
forward.  This  is  demonstrated  by  extending  the  arms  in  front 
to  a  right  angle,  the  gliding  forward  of  the  scapula  upon  the 
sound  side  being  marked  and  upon  the  diseased  side  being 
slight  or  absent. 

Treatment  of  dislocation  of  the  lower  angle  of  the  scapula 
comprises  massage,  electricity,  passive  motion,  and  deep  in- 
jections of  strychnin. 

Simultaneous  dislocation  of  both  ends  of  the  clavicle  is  a 
very  rare  injury.     It  is  treated  as  is  single  dislocation. 

Dislocations  of  the  Humerus  (Shoulder-joint). — These 
injuries  are  quite  frequent  because  of  the  free  mobility  of  the 
shoulder-joint,  its  anatomical  insecurity,  and  its  exposed  situ- 
ation ;  they  rarely  occur  in  the  very  young  and  in  the  aged, 
and  are  oftenest  encountered  in  muscular  young  adults. 
Four  chief  forms  of  shoulder-joint  dislocation  exist,  namely: 
(i)  forward,  inward,  and  downward,  under  the  coracoid  pro- 
cess— subcoracoid ;  (2)  downward,  forward,  and  inward,  be- 
neath the  glenoid  cavity — subglenoid ;  (3)  backward,  in- 
ward, and  downward,  under  the  spine  of  the  scapula — 
subspinous ;  and  (4)  forward,  inward,  and  upward,  under 
the  clavicle — subclavicular. 

A  very  rare  form  of  shoulder-joint  dislocation  has  been 
described,  which  is  known  as  the  "  supracoracoid."  Another 
rare  form  is  the  luxatio  erecta. 

Subcoracoid  Luxation. — The  subcoracoid  variety  of  dis- 
location embraces  three-fourths  of  all  the  shoulder-joint 
luxations.  It  may  be  caused  by  direct  force  driving  the 
head  of  the  humerus  forward  and  inward,  or  by  indirect 
force,  such  as  falls  upon  the  hand  or  the  elbow.  In  this 
dislocation  the  anatomical  neck  of  the  humerus  lies  upon 
the    anterior   margin    of   the    glenoid   cavity,  just   beneath 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    449 

the  coracoid  process,  and  is  above  the  tendon  of  the  sub- 
scapularis  muscle. 

Subglenoid  or  axillary  fixation  may  be  produced  by  con- 
traction of  the  great  pectoral  and  latissimus  dorsi  muscles 
when  the  arm  is  at  a  right  angle  to  the  body,  but  it  is  usually 
due  to  falls  upon  the  hand  or  the  elbow  when  the  arm  is 
raised  and  the  head  of  the  bone  is  against  the  lower  portion 
of  the  capsule.  In  this  dislocation  the  head  of  the  bone  rests 
upon  the  border  of  the  scapula,  below  the  tendon  of  the  sub- 
scapularis,  in  front  of  the  long  head  of  the  triceps,  and  above 
the  teres  muscles.  Some  observers  hold  that  most  disloca- 
tions of  the  shoulder  are  primarily  subglenoid,  the  position 
having  been  altered  by  muscular  action. 

Subspinous  luxation  is  a  rare  injury.  Pick  met  with  this 
accident  in  a  man  who,  while  having  his  hands  in  his  pockets, 
fell  upon  the  front  of  the  point  of  the  shoulder.  The  head 
of  the  bone  reposes  beneath  the  scapular  spine,  between  the 
infraspinatus  and  teres  minor  muscles. 

Subclavicular  luxation  is  very  rare.  It  is  caused  by  the  same 
sort  of  violence  which  produces  subcoracoid  luxation.  The 
head  of  the  bone  rests  upon  the  thorax,  below  the  clavicle 
and  underneath  the  pectoralis   major  muscle. 

In  the  rare  form  known  as  the  "  supracoracoid  "  the  head 
of  the  humerus  rests  upon  the  coraco-acromial  ligament  or 
upon  the  acromion  process  and  the  acromion  or  the  coracoid 
is  always  fractured. 

Luxatio  erccta  is  an  unusual  form  of  subglenoid  dislocation. 
The  arm  is  upright  and  the  forearm  rests  behind  the  occiput 
or  on  the  top  of  the  head,  and  the  patient  holds  it  there  to 
avoid  pain.     Judd,  Hulke,  and  Cleland  have  related  cases. 

Symptoms  of  Dislocation  of  the  Shoulder-Joint. — Dislocation 
is  diagnosticated  by  (i)  pain  of  a  sickening  character  ;  (2)  flat- 
tening of  the  shoulder,  the  head  of  the  bone  having  ceased  to 
bulge  out  the  deltoid  muscle ;  (3)  apparent  projection  of 
the  acromion  through  sinking  in  of  the  deltoid ;  (4)  hollow 
beneath  the  acromion,  over  the  empty  glenoid  cavity,  and  the 
bone  missed  from  its  normal  habitat.  This  hollow  may  be 
easily  appreciated  by  the  finger,  especially  when  the  extrem- 
ity is  somewhat  abducted ;  (5)  rigidity  (some  movement  is 
possible,  in  the  direction  especially  of  an  existing  deformity, 
but  mobility  is  strictly  limited  and  attempts  at  motion  pro- 
duce great  pain) ;  (6)  the  elbow  cannot  touch  the  side  when 
the  hand  is  placed  upon  the  sound  shoulder,  and  the  hand 
cannot  be  placed  upon  the  sound  shoulder  if  the  elbow  is  to 
the  side — Dugas's  sign  (this  is  due  to  the  rotundity  of  the 

29 


450 


MODERN  SURGERY. 


chest.  In  a  dislocation  the  head  of  the  bone  is  already  touch- 
ing the  chest,  and  the  bone,  being  approximately  straight, 
cannot  touch  it  in  two  places  at  the  same  time.  If  the  elbow 
can  be  placed  against  the  chest  with  the  hand  on  the  sound 
shoulder,  there  cannot  be  dislocation ;  if  it  cannot  be  so 
placed,  there  must  be  dislocation) ;  (7)  finding  the  head  of 
the  bone  in  a  new  situation ;  (8)  examining  by  means  of 
the  A^'-rays.  Symptoms  i  to  5  inclusive  may  be  grouped  as 
Erichsen's  list  of  signs.  The  form  of  dislocation  is  made 
out  by  a  study  of  the  direction  of  the  axis  of  the  limb,  the 
existence  and  extent  of  .lengthening  or  of  shortening,  and 
the  situation  of  the  head  of  the  bone. 

The  following  table  from  T.  Pickering   Pick's  work   on 
Fractures  and  Dislocations  makes  the  above  points  clear : 


Subcoracoid. 


Subglenoid. 


Subspinous. 


Subclavicular. 


Direction  of  the 
Axis  of  the  Limb. 


The  elbow  is  car- 
ried backward  and 
slightly  away  from 
the  side. 

The  elbow  is  car- 
ried away  from  the 
trunk  and  slightly 
backward. 

The  elbow  is 
raised  from  the  side 
and  carried  for- 
ward. 

The  elbow  is  car- 
ried outward  and 
backward. 


Alteration  in  the 
Length  of  the  Limb. 


Very     slight 
lengthening. 


Very  consider- 
able lengthening. 


Lengthening  in- 
termediate in  de- 
gree between  the 
subglenoid  and  the 
subcoracoid. 

Shortening. 


Presence    of     the     Head 

of  the  Bone  in  New 

Situation. 


The  head  of  the 
bone  cannot  easily  be 
felt;  if  it  can,  it  is 
found  at  the  upper  and 
inner  part  of  the  axilla. 

The  head  of  the 
bone  can  easily  be  felt 
in  the  axilla. 

The  head  of  the 
bone  can  be  felt  and  be 
grasped  beneath  the 
spine  of  the  scapula. 

The  head  of  the 
bone  can  readily  be 
seen  and  be  felt  be- 
neath the  clavicle. 


In  a  shoulder-joint  dislocation  the  head  of  the  bone  may 
press  upon  the  brachial  plexus  and  produce  pain  and  numb- 
ness, and  occasionally  a  traumatic  neuritis  or  paralysis  ;  some- 
times pressure  upon  the  axillary  vein  causes  intense  edema, 
and  pressure  upon  the  axillary  artery  diminishes  or  obHter- 
ates  the  pulse.  The  axillary  vessels  may  be  torn  and  the 
muscles  may  be  lacerated  badly.  The  capsule  is  torn  and 
con.siderable  blood  is  usually  effused.  Swelling  is  due  first 
to  hemorrhage,  and  secondly  to  inflammation.  Partial  dis- 
locations sometimes,  though  rarely,  occur.  What  is  usually 
spoken  of  as  "  partial  dislocation "  or  "  subluxation "  is  a 
condition  in  which  the  head  of  the  humerus  passes  forward 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    45  I 

under  the  coracoid  because  of  rupture  of  the  long  head  of 
the  biceps  or  because  this  tendon  slips  out  of  its  groove,  the 
ligaments  being  intact. 

Diagnosis  of  Shojtldcr-joiiit  Dislocation. — In  fracture  of  the 
neck  of  the  scapula  there  is  prominence  of  the  acromion  and 
a  hollow  below  it,  a  hard  body  being  felt  in  the  axilla ;  but 
the  coracoid  process  descends  with  the  head  of  the  bone, 
which  it  does  not  do  in  dislocation.  Furthermore,  in  fract- 
ure there  is  mobility ;  in  dislocation  rigidity.  In  fracture 
crepitus  is  present ;  in  dislocation  it  is  absent.  In  fracture 
the  deformity  is  easily  reduced,  but  it  at  once  recurs ;  in  dis- 
location the  deformity  is  with  difficulty  reduced,  but  does 
not  recur.  In  fracture  the  elbow  can  be  made  to  touch  the 
side  when  the  hand  is  upon  the  sound  shoulder ;  in  disloca- 
tion it  cannot  be  so  manipulated.  In  fracture  of  the  anatomi- 
cal neck  of  the  humerus  deformity  is  slight ;  the  head  of  the 
humerus  is  found  in  place,  and  does  not  move  when  the  shaft 
is  rotated ;  and  the  head  is  not  in  line  with  the  axis  of  the 
bone.  Crepitus  exists  in  fracture  if  impaction  is  absent.  In 
paralysis  of  the  deltoid  there  is  distinct  flattening,  but  the 
bone  is  felt  in  place  and  there  is  no  rigidity.  The  A-rays 
are  a  great  aid  to  diagnosis. 

Treatinoit  of  SJiouldcr-joiiit  Dislocation. — Reduction  by 
manipulation  is  usually  readily  obtained  in  recent  cases  of 
shoulder-joint  dislocation.  It  is  usually  well  to  give  ether. 
Forward  dislocations  (subcoracoid,  subclavicular,  and  axillar}-) 
are  reduced  by  Kocher's  method  (Fig.  no):   Put  the  arm 


Fig.  iio. — Kocher's  method  of  reduction  by  manipulation  :  a,  first  movement,  outward 
rotation  ;  h,  second  movement,  elevation  of  elbow  ;  c,  third  movement,  inward  rotation  and 
lowering  of  the  elbow  (Ceppi). 


against  the  side,  flex  the  forearm  to  a  right  angle  with  the 
arm,  perform  external  rotation  of  the  arm  until  resistance  be- 
comes decided,  raise  the  elbow,  make  internal  rotation,  bring 
the  arm  across  the  front  of  the  chest  and  lower  the  elbow. 
The  formula  is,  flexion  of  the  forearm,  external  rotation,  lift- 


452  MODERN  SURGERY. 

ing  elbow  forward,  internal  rotation  of  the  arm,  and  lowering 
the  elbow.  If  in  trying  Kocher's  plan  external  rotation  of  the 
humerus  does  not  take  place,  abandon  the  method,  as  per- 
sistence will  fracture  the  humerus.  Another  method  of  ma- 
nipulation is  as  follows  :  if  the  right  shoulder  is  dislocated, 
the  surgeon  stands  behind  the  patient  (who  is  sitting  erect) ; 
if  the  left  shoulder  is  dislocated,  he  stands  in  front  of  the 
patient.  The  surgeon  holds  the  forearm  flexed  upon  the 
arm  with  his  right  hand  and  makes  external  traction  and 
rotation,  and  with  the  fingers  of  his  left  hand  he  tries  to  force 
the  bone  into  place. 

In  Henry  H.  Smith's  method  for  forward  dislocations  the 
surgeon  stands  in  front  of  the  patient.  If  the  left  shoulder 
is  dislocated,  the  surgeon  grasps  it  with  his  left  hand ;  if  the 
right  shoulder  is  dislocated,  he  grasps  it  with  his  right  hand, 
the  thumb  resting  on  the  head  of  the  bone.  With  his  disen- 
gaged hand  the  surgeon  grasps  the  elbow,  abducts  it,  makes 
traction  and  external  rotation,  and  suddenly  sweeps  the  elbow 
inward,  aiming  it  at  the  sternum,  and  tries  with  his  thumb  to 
push  the  bone  into  place.  In  subspinous  luxations  reduction 
may  be  effected  if  the  surgeon  stands  behind  the  patient, 
makes  abduction,  traction,  and  internal  rotation,  sweeps  the 
elbow  inward  toward  the  spine,  and  with  the  thumb  aids  the 
bone  in  its  return  into  position.  Raising  the  elbow  far  above 
the  head  and  sweeping  it  inward  will  reduce  some  disloca- 
tions. As  the  head  of  the  bone  slips  back  a  distinct  jar  is 
felt  and  a  snap  is  heard,  the  motions  of  the  joint  are  again 
obtainable,  and  with  the  hand  on  the  opposite  shoulder  the 
elbow  may  be  made  to  touch  the  side. 

Reduction  by  Extension. — In  reduction  of  shoulder-joint 
dislocation  by  extension  the  patient  is  anesthetized  and 
placed  upon  a  low  bed  or  upon  the  floor.  The  surgeon 
then  places  his  foot,  covered  only  by  a  stocking,  in  the  axilla. 
Place  the  sole  of  the  foot,  not  the  heel,  against  the  chest  high 
up,  the  instep  being  made  to  touch  the  humerus  and  the  heel 
the  border  of  the  shoulder-blade,  a  towel  being  first  put  into 
the  axilla  to  rest  the  foot  against  (Fig.  in).  If  the  left  arm 
is  dislocated,  use  the  left  foot,  and  vice  versa.  The  elder 
Gross  approved  of  making  extension  while  sitting  between 
the  patient's  limbs.  Make  steady  extension,  which  will  in 
many  cases  bring  about  the  reduction.  If  it  fails  to  cause 
reduction,  bring  the  patient's  arm  across  the  chest  and  use 
the  foot  as  the  fulcrum  of  a  lever.  If  the  humerus  is  pretty 
firmly  fixed  in  its  abnormal  position,  make  counter-extension 
with  a  foot  in  the  axilla  and  make  extension  by  fixing  a  clove- 


DISEASES  AND   INJURIES   OF  BOXES  AND  JOINTS.    453 

hitch  (Fig.  1 1 2)  above  the  clbozv  and  fastening  to  it  bands  which 
go  over  one  shoulder  and  under  the  other  shoulder  of  the 
surgeon.  The  back  may  be  used  for  extension,  the  hands 
being  left  free  for  manipulation  (Allis's    and   Pick's   plan). 


Fig.  III. — Reduction  of  shoulder-joint  disloca- 
tion by  the  foot  in  the  axilla  (Cooper). 


Fig.  112. — Clove-hitch  knot  applied 
above  the  wrist  In  dislocation  of  the 
shoulder  this  knot  is  put  above  the  elbow 
(after  Erichsen). 


Lateral  extension  is  used  by  some  surgeons.  The  patient 
lies  down,  a  large  piece  of  canvas  is  split,  the  arm  is  passed 
through  the  split  and  the  body  is  thus  fixed.  The  arm  is 
pulled  to  a  right  angle  with  the  body  and  traction  is  applied. 
The  late  Prof  Joseph  Pancoast  favored  Sir  Astley  Cooper's 
method  of  placing  the  unanesthetized  patient  in  a  chair  and 
using  the  knee  as  a  fulcrum,  pushing 
the  elbow  to  the  side  (Fig.  113). 
Brunus,  in  the  thirteenth  century, 
devised  the  method  of  upward  ex- 
tcnsio)i.      In    appl}-ing   this    method 


Fig.  113.— Reduction  of  shoul- 
der-joint dislocation  by  the  knee 
in  the  axilla  (Cooper). 


Fig.  114. — Reduction  of  shoulder-joint  disloca- 
tion by  upward  extension  (Cooper). 


the  surgeon  takes  his  place  behind  the  patient,  steadies  the 
scapula  with  his  hand,  and  carries  the  patient's  arm  upward 
and  backward  above  his  head,  making  extension  and  external 
rotation  (Fig.  114).  La  IVIothe's  method  is  applied  with  the 
patient  supine  upon  the  floor.     The  surgeon  places  his  foot 


454  MODERN  SURGERY. 

upon  the  shoulder  to  make  counter-extension,  and  makes 
extension  as  in  Brunus's  method.  It  is  a  useful  expedient, 
when  either  of  these  plans  is  applied,  to  have  an  assistant 
make  the  traction  while  the  surgeon  manipulates  the  head 
of  the  bone.  Cock  advises,  when  reduction  fails,  that  an 
air-pad  be  placed  in  the  axilla  and  the  arm  be  bound  to  the 
side — a  method  by  which  reduction  will  often  take  place  after 
two  or  three  days.  The  pulleys  should  not  be  used,  as  they 
develop  a  dangerous  force,  antiseptic  incision  being  a  safer 
and  a  better  expedient.  After  incision  tr}'  to  restore  the  bone 
to  place.  In  an  old  dislocation  it  may  be  necessary  to  resect 
the  head  of  the  bone. 

In  reducing  a  dislocation  the  axillar}'  artery  or  vein  may 
be  ruptured,  fracture  of  the  neck  of  the  humerus  may  take 
place,  injury  to  the  brachial  artery  may  occur,  or  the  soft 
parts  may  be  badly  damaged.  After  reducing  a  dislocation 
apply  a  Velpeau  bandage,  keep  the  shoulder  immobile  for 
one  week,  then  make  passive  motion  daily,  reapplying  the 
dressing  after  each  seance.  The  patient  may  wear  a  sling 
alone  during  the  third  week,  after  which  period  he  may  use 
the  arm.  (For  old  dislocations  and  compound  dislocations 
see  page  443.)  Reduction  of  old  dislocations  may  sometimes 
be  effected  by  manipulation.  Extension  may  have  to  be  used, 
and  ether  may  be  required.  In  old  dislocations  tiy  to  reduce, 
after  breaking  up  adhesions,  by  forced  flexion  and  strong  ex- 
tension. After  reduction  immobilize  for  three  weeks,  and 
begin  passive  motion  after  seven  days. 

If  a  dislocation  is  complicated  by  a  fracture  of  the  humerus, 
try  to  pull  the  head  of  the  bone  opposite  the  joint.  This 
may  be  possible  if  the  two  fragments  are  held  partly  together 
by  a  fair  amount  of  periosteum,  and  muscle.  Traction  is  made 
upon  the  arm,  and  an  attempt  is  made  to  manipulate  the  head 
into  the  socket  (Allis's  plan  in  the  hip).  McBurney  incises, 
fixes  a  hook  in  the  scapula  and  a  hook  in  the  head  of  the 
humerus,  pulls  the  head  into  place,  and  wires  the  fragments 
(Figs,  ^y,  68,  69).  In  an  emergency  gimlets  may  be  used 
instead  of  the  hooks.  In  some  cases  it  is  necessary  to  excise 
the  head  of  the  bone. 

Dislocations  of  the  Elbow-joint. — Injuries  of  the  elbow- 
joint  are  not  rare,  and  they  are  commonest  in  children. 
Both  bones  or  only  one  bone  may  be  dislocated,  and  the 
dislocation  may  be  partial  or  complete. 

Dislocation  of  Both  Bones  Backward, — The  causes  of 
backward  dislocation  of  both  bones  of  the  forearm  are 
falls   upon  the  extended  hand  or  twists  inward  of  the  ulna 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    455 


(Malgaigne).     The  coronoid  process  lodges  in  the  olecranon 
fossa  of  the  humerus. 

Syuiptouis  of  Backzvard  Dislocation. — In  complete  disloca- 
tion of  both  bones  of  the  forearm  the  olecranon  is  very 
prominent ;  the  distance  between  the  point  of  the  olecranon 
and  the  apex  of  the  inner  condyle  is  notably  greater  than  on 
the  sound  side ;  the  forearm  is  flexed,  supinated,  and  short- 
ened ;  the  lower  end  of  the  humerus  projects  in  front  of  the 
joint,  below  the  skin-crease ;  the  head  of  the  radius  is  found 
back  of  the  outer  condyle ;  and  there  are  the  general  symp- 
toms of  dislocation.  Fracture  of  the  coronoid  rarely  occurs 
with  backward  dislocation,  but  if  it  does  occur  there  will 
be  crepitus  and  mobility.  Fracture  at  the  base  of  the  con- 
dyles is  distinguished  from  dislocation  of  both  bones  of  the 
forearm  backward  by  the  following  points  :  in  fracture  there 
are  found  the  ordinary  symptoms ;  measurement  from  the 
condyles  to  the  styloid  processes  does  not  show  shortening ; 
there  is  no  alteration  of  the  normal  relation  between  the  olec- 
ranon process  and  the  condyles ;  and  the  projection  in  front 
of  the  joint  is  above  the  crease  of  the  bend  of  the  elbow. 

Treatment  of  Backiuard  Dislocation. — Reduction  must  be 
effected  early  in  dislocation  of  both  bones  of  the  forearm, 
or  it  will  be  found  impos- 
sible, and  an  unreduced 
dislocation  means  a  limb 
without  the  powers  of 
flexion,  pronation,  and 
supination.  The  surgeon 
places  his  knee  in  front 
of  the  elbow-joint,  grasps 
the  patient's  wTist,  presses 
upon  the  radius  and  ulna 
with  his  knee,  and  bends 
the  forearm  with  consid- 
erable force,  the  muscles 
pulling  the  bones  into  place  (Sir  Astley  Cooper's  plan). 
Forced  flexion,  traction,  and  extension  may  be  tried  (Fig. 
115).  Put  the  arm  in  Jones's  position  for  two  weeks,  and 
make  passive  motion  daily  after  the  first  few  days. 

Dislocation  of  Both  Bones  Forward. — The  cause  of  for- 
ward dislocation  of  both  bones  of  the  forearm  is  a  blow 
on  the  olecranon  when  the  arm  is  flexed.  It  is  a  rare 
accident. 

Symptoms  and  Treatment. — The  symptoms  of  forward 
dislocation  of    both    bones  of    the    forearm    are — forearm 


Fig.  115. — Reduction  of  elbow-joint  dislocation. 


456  MODERN  SURGERY. 

is  flexed  and  lengthened ;  some  slight  motion  is  possible ; 
olecranon  is  on  a  level  with  the  condyles  if  unfractured, 
hence  its  prominence  is  gone ;  the  humeral  condyles  are 
felt  posteriorly,  and  the  radius  and  ulna  are  felt  anteriorly. 
The  treatment  of  this  injury  consists  in  early  reduction,  which 
is  accomplished  by  means  of  forced  flexion  and  pressure, 
placing  the  part  in  Jones's  position  for  two  weeks,  and 
making  passive  motion  daily  after  the  first  few  days. 

Lateral  dislocations  of  both  bones  of  the  forearm  are 
usually  incomplete. 

Symptoms  and  Treatment  of  Outward  Dislocatio)i.-^-Th& 
symptoms  of  outward  dislocation  of  both  bones  of  the 
forearm  are — forearm  is  flexed,  fixed,  and  pronated;  joint 
is  widened ;  the  head  of  the  radius  projects  externally 
and  has  a  depression  above  it;  the  inner  condyle  projects 
internally  and  has  a  depression  below  it ;  the  olecranon  is 
nearer  than  normal  to  the  external  condyle  and  further 
than  normal  from  the  internal  condyle.  Reduction  is  ef- 
fected by  extension  of  the  forearm  and  pressure  inward  upon 
the  head  of  the  radius.  Apply  an  ascending  spiral  reverse 
bandage  of  the  forearm,  a  figure-of-8  bandage  of  the  elbow- 
joint,  and  a  sHng.  Make  passive  motion  after  a  few  days. 
The  bandages  must  be  worn  for  two  weeks. 

Symptoms  and  Treatment  of  Inward  Dislocation. — In  dis- 
location inward  of  both  bones  of  the  forearm  the  posi- 
tion of  the  forearm  is  the  same  as  that  in  dislocation  out- 
ward; the  sigmoid  cavity  of  the  ulna  projects  internally,  and 
the  external  condyle  projects  externally.  Reduction  is 
effected  by  extension  of  the  forearm  and  pressure  outward 
on  the  ulna,  subsequent  treatment  being  the  same  as  that 
employed  in  the  preceding  form. 

Dislocation  of  the  ulna  alone  is  very  rare,  and  can  only 
take  place  backward. 

Symptoms  and  Treatment. — Dislocation  of  the  ulna  alone 
is  indicated  by  the  forearm  being  flexed  and  pronated.  The 
head  of  the  radius  is  found  in  place,  and  the  olecranon  pro- 
jects posteriorly.  The  treatment  of  this  injury  is  the  same 
as  that  for  dislocation  of  both  bones. 

Dislocation  of  the  Radius  Forward. — Dislocation  of  the 
radius  forward  is  the  commonest  form  of  dislocation  of  the 
elbow.  This  injury  is  caused  by  a  fall  upon  the  hand  with 
the  forearm  in  pronation  and  extension,  or  is  produced  by 
blows  on  the  back  of  the  joint ;  forced  pronation  alone  will 
not  cause  it. 

Symptoms  and  Treatment. — The  symptoms  in  dislocation 


DISEASES  AXD   IXJCRIES   OF  BONES  AND  JOINTS.    457 

of  the  radius  forward  are — forearm  midway  between  prona- 
tion and  supination,  and  semiflexed ;  attempts  to  increase 
flexion  cause  the  radius  to  strike  against  the  humerus  with 
a  distinct  blow ;  the  head  of  the  radius  is  felt  in  front  of 
the  outer  condyle  and  is  missed  from  its  proper  abode.  Re- 
duction is  effected  by  flexion  over  the  knee,  extension,  and 
manipulation.  Subsequent  treatment  is  Jones's  position  and 
passive  motion.  Deformity  is  apt  to  recur  after  reduction, 
because  of  rupture  of  the  orbicular  ligament. 

Dislocation  of  the  radius  backward  is  caused  by  falls 
on  the  hand  or  by  blows  on  the  front  of  the  joint. 

Syiiiptoj/ts  and  Treatment. — Backward  dislocation  of  the 
radius  is  indicated  by  the  forearm  being  slightly  flexed 
and  fixed  in  pronation,  by  some  impairment  of  flexion  and 
extension,  and  by  the  radius  being  felt  behind  the  outer 
condyle.  Reduction  is  effected  by  flexion  over  the  knee, 
extension,  and  manipulation,  and  the  subsequent  treatment 
is  the  same  as  that  given  for  the  preceding  dislocation. 

Dislocation  of  the  radius  outAvard  is  very  rare.  In 
this  injur}^  the  head  of  the  radius  is  distinctly  felt.  Reduc- 
tion is  effected  by  extension  and  pressure ;  the  subsequent 
treatment  is  the  same  as  that  for  the  above-mentioned  dis- 
locations. 

Subluxation  of  the  Head  of  the  Radius. — This  name  is 
given  to  an  injury  which  is  ver>'  frequent  in  children  between 
two  and  four  years  of  age.  It  results  from  traction  upon  the 
hand  or  the  forearm,  and  often  arises  when  the  nurse  or  the 
mother  pulls  upon  a  child's  arm  to  save  it  from  a  fall  or  to 
lift  it  over  a  gutter.  Some  writers  hold  that  pronation  is 
required,  as  well  as  extension,  to  produce  the  injury;  many 
surgeons  claim  that  extension  and  adduction  are  the  causa- 
tive forces.  Hutchinson  maintains  that  supination  may  cause 
subluxation.     Bardenheuer  assigned  falls  as  causes. 

The  symptoms  are  very  characteristic.  The  histor}'  points 
to  the  injur)^  Pain,  and  often  a  click,  may  be  felt  in  the 
wrist  at  the  time  of  the  accident.  The  arm  hangs  by  the 
side,  with  the  elbow-joint  slightly  flexed  and  the  forearm 
midway  between  pronation  and  supination.  Flexion  to  a 
less  angle  than  60°  and  complete  extension  are  resisted  and 
are  very  painful,  but  movements  between  60°  and  130°  are 
free  and  painless.^  The  movements  of  the  wrist-joint  are 
free  and  painless.  The  elbow-joint  presents  no  deformity. 
Pressure  over  the  head  of  the  radius  causes  pain.     Strong 

'  See  the  instructive  article  by  \V.  W.  Van  Arsdale,  in  the  Amiah  of  Surgery, 
vol.  ix.,  1889. 


458  MODERN  SURGERY. 

pronation  is  painful ;  strong  supination  is  very  painful,  and 
there  seems  to  be  a  mechanical  obstacle  to  its  performance. 
Forced  supination  develops  a  distinct  click  at  the  head  of 
the  radius,  and  causes  pronation  and  supination  to  become 
natural  and  free  from  pain.  The  condition  will  be  repro- 
duced if  a  splint  is  not  used.  The  nature  of  the  lesion  is  not 
understood,  and  various  conditions  have  been  thought  to 
exist  by  different  observers.  Among  them  may  be  men- 
tioned the  following :  a  slight  anterior  displacement  of  the 
head  of  the  radius ;  a  slight  posterior  displacement ;  locking 
of  the  tuberosity  of  the  radius  behind  the  inner  edge  of  the 
ulna ;  dislocation  of  the  triangular  cartilage  of  the  wrist ; 
intracapsular  fracture  of  the  radial  head ;  painful  paralysis 
from  nerve-injury ;  displacement  by  elongation,  the  return 
of  the  bone  being  prevented  by  collapse  of  the  capsule ;  and 
the  slipping  up  of  the  margin  of  the  orbicular  ligament  over 
the  rim  of  the  head  of  the  radius. 

Ti'eatment. — Place  the  forearm  at  a  right  angle  to  the  arm 
and  make  forcible  supination ;  apply  an  anterior  angular 
splint,  and  have  it  worn  for  four  or  five  days,  or  put  the 
part  in  Jones's  position  for  an  equal  period. 

Dislocations  of  the  "wrist,  which  are  very  rare,  are 
caused  by  falls  upon  the  hand. 

Back-ward  Dislocation  of  the  "Wrist. — Symptoms. — The 
deformity  in  backward  dislocation  of  the  wrist  (Fig.  ii6,  a) 
resembles  that  of  Colles's  fracture  (Fig.  1 16,  b).  The  fingers 
are  flexed,  the  wrist  is  bent  backward,  the  radius  projects 


Fig.  ii6. — Deformity  in  dislocation  of  the  wrist  backward  (a)  and  in  Colles's  fracture  (b) 

(Stimson). 

on  the  front  of  the  wrist,  the  carpus  projects  on  the  dorsal 
surface  of  the  forearm,  the  relation  of  the  styloid  process  of 
the  radius  to  the  styloid  process  of  the  ulna  is  unaltered  (it  is 
altered  in  Colles's  fracture),  there  is  rigidity,  and  crepitus  is 
absent  (Fig.  1 16). 

Forward  dislocation  of  the  -wrist,  which  is  very  unusual, 
is  caused  by  a  fall  upon  the  back  of  the  hand. 

Symptoms  and  Treatment. — In  forward  dislocation  of  the 
wrist  the  radius  and  ulna  project  posteriorly  and  the  carpus 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    459 

projects  in  front.  The  treatment  in  both  of  these  dislocations 
is  reduction  by  extension  and  manipulation,  the  use  of  a  Bond 
splint  for  ten  days,  and  the  employment  of  passive  motion 
after  five  or  six  days. 

Dislocation  at  the  inferior  radio-ulnar  articulation, 
which  is  also  very  rare,  is  caused  by  twists. 

Symptoms  and  Treatment. — In  forzuard  dislocation  at  the 
inferior  radio-ulnar  articulation  the  forearm  is  pronated,  the 
space  between  the  styloid  processes  is  diminished,  and  the 
ulna  forms  a  projection  posteriorly.  In  backivard  disloca- 
tion the  forearm  is  supinated,  the  space  between  the  styloid 
processes  is  diminished,  and  the  ulna  projects  in  front.  Re- 
duction is  accomplished  by  extension  and  manipulation.  Two 
straight  splints  (as  in  fracture  of  both  bones)  are  to  be  ap- 
plied for  four  weeks,  and  passive  motion  is  to  be  made  in 
the  third  week. 

Dislocation  of  Individual  Carpal  Bones. — Pick  says 
there  is  one  weak  spot,  which  is  "  between  the  head  of  the 
OS  magnum  and  the  scaphoid  and  semilunar  bones,"  and  the 
OS  magnum  may  be  forced  up.  The  os  magnum  is  the  only 
bone  dislocated  with  any  frequency,  and  the  injury  is  caused 
by  forced  flexion  of  the  wrist. 

Symptoms  and  Treatment. — The  symptom  of  dislocation 
of  the  carpal  bones  is  a  firm  projection  which  becomes  more 
prominent  during  flexion  of  the  wrist.  The  treatment  is  ex- 
tension and  manipulation,  a  Bond  splint  being  worn  for  three 
weeks. 

Dislocations  of  metacarpal  bones  are  rare.  The  first 
metacarpal  bone  is  most  liable  to  dislocation. 

Symptoms  and  Treatment. — Dislocations  of  the  metacarpal 
bones  are  obvious  because  of  projection.  The  dislocations 
are  reduced  by  extension  and  manipulation,  a  straight  splint 
and  large  pad  for  the  palm  are  applied  (as  in  fracture  of  the 
metacarpus),  and  the  splint  is  to  be  worn  for  three  weeks. 

Dislocations  at  the  metacarpophalangeal  articulations 
are  rare,  and  backward  dislocation  is  the  most  common. 
The  cause  is  a  fall  upon  the  hand. 

Symptoms  and  Treatment. — Dislocated  metacarpophalan- 
geal articulations  are  obvious.  Reduction  is  easily  effected 
by  extension  and  manipulation,  except  in  the  case  of  the 
thumb.     A  splint  must  be  worn  for  three  weeks. 

Dislocation  of  the  Metacarpophalangeal  Joint  of  the 
Thumb. — In  this  dislocation  the  phalanx  usually  passes 
backward. 

Symptoms. — Symptoms  of  backzvard  dislocation  are — the 


460 


MODERN  SURGERY. 


base  of  the  first  phalanx  rests  upon  the  metacarpal  bone ; 
the  head  of  the  metacarpal  bone  projects  forward  and  button- 
holes the  muscles  of  the  thumb  ;  the  first  phalanx  of  the 
thumb  is  strongly  extended,  and  the  terminal  phalanx  is 
semiflexed.  The  symptoms  oi  forward  dislocation  are — the 
base  of  the  first  phalanx  is  felt  in  the  palm,  and  the  head  of 
the  metacarpal  bone  is  felt  posteriorly. 

Treatment. — In  treating  backward  dislocation  of  the  meta- 
carpophalangeal joint  of  the  thumb,  reduction  is  difficult 
because  of  the  head  of  the  bone  being  caught  in  the  perfora- 
tion of  the  flexor  muscle.  Always  give  ether.  Keetley's 
directions  are  to  adduct  the  metacarpal  bone  into  the  palm 
(to  relax  the  muscles)  and  to  have  an  assistant  hold  it ; 
bend  the  thumb  strongly  back,  extend,  pull  the  thumb 
toward  the  fingers,  and  suddenly  flex.  To  get  a  firm 
enough  grasp  for  these  manipulations  use  the  apparatus 
of  Charriere  or  of  Levis  (Figs.  117,  118).  If  the  above 
maneuvers    fail,    perform    tenotomy    or    incise    freely    and 


Fig.  117. — Levis's  splint  for  reducing  dislocation  of  phalanges. 


Fig.  118. — Levis's  splint  applied. 

reduce.  After  reduction  of  this  dislocation  a  splint  must 
be  worn  for  three  weeks.  In  forward  dislocation  reduction 
is  easily  effected  by  strong  extension  and  forced  flexion.  A 
splint  is  to  be  worn  for  three  weeks. 

Dislocations  of  the  phalanges  may  be  complete  or  may  be 
partial.  They  are  commonest  between  the  first  and  second 
phalanges. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges 
are  obvious.  In  treating  such  dislocations  employ  extension 
and  manipulation,  and  use  a  splint  for  one  week. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    46 1 

Dislocations  of  the  Ribs  and  Costal  Cartilages. — The 
ribs  may  be  dislocated  from  the  vertebrae.  This  accident  is 
rarely  uncomplicated,  and  cannot  be  differentiated  from  fract- 
ure. The  diagnosis  is  rarely  made,  and  the  injury  is  treated 
as  a  fracture.  The  ribs  may  be  dislocated  from  their  carti- 
lages, one  or  more  ribs  being  displaced.  The  end  of  the  rib 
forms  an  anterior  projection,  there  is  a  depression  over  the 
cartilage,  and  crepitus  is  absent.  Treatment  is  the  same  as 
that  employed  for  fractured  ribs.  The  costal  cartilages  may 
be  displaced  from  the  sternum,  forming  an  anterior  projec- 
tion upon  this  bone.  Reduction  is  brought  about  by  placing 
the  patient  upon  a  table,  with  a  sand  pillow  between  the 
scapuljE,  pushing  back  the  shoulders  and  chest,  and  forcing 
the  cartilage  into  place.  The  dressings  are  the  same  as  those 
used  in  fractured  sternum.  The  cartilages  of  the  lower  ribs 
(sixth,  seventh,  eighth,  ninth,  and  tenth)  may  be  separated. 
The  inferior  cartilage  goes  forward  and  can  be  felt.  Pick 
states  that  reduction  is  brought  about  by  causing  the  patient 
to  hold  the  chest  full  of  air  while  efforts  are  made  to  push 
the  cartilage  into  place.     Dress  as  for  fractured  ribs. 

Dislocations  of  the  Sternum. — In  dislocations  of  the 
sternum  the  manubrium  may  be  separated  from  the  gladio- 
lus in  young  subjects.  The  symptoms  and  treatmettt  are  the 
same  as  those  in  fracture  (page  353). 

Pelvic  dislocations  are  almost  always  complicated  with 
fracture.  A  pubic  bone  can  be  dislocated  by  falls  from  a 
height  or  by  applying  violent  force  to  the  acetabula.  The 
dislocation  may  be  up  or  down,  front  or  back,  and  it  may 
damage  the  urethra  or  the  bladder.  The  patient  cannot 
stand  ;  there  are  great  pain  and  recognizable  deformity.  Treat 
by  moulding  the  bones  into  place,  by  applying  a  pelvic  belt, 
and  by  rest  in  bed  for  four  weeks.  Dislocations  of  the 
sacro-iliac  joint  are  produced  by  falls.  Movement  on  the 
part  of  the  patient  is  difficult  or  impossible ;  there  is  violent 
pain,  and  often  paralysis  (from  pressure  upon  nerves).  In 
dislocation  backward  there  is  an  apparent  shortening  of  the 
leg,  eversion  of  the  foot  exists,  and  the  ilium  moves  poste- 
riorly and  upward.  In  dislocation  forward  the  anterior  supe- 
rior iliac  spine  projects  and  the  pelvis  is  broadened.  Sacro- 
iliac dislocations  are  reduced  by  holding  the  pelvis  firm  and 
making  extension  with  a  pulley.  The  patient  stays  in  bed 
for  four  weeks  and  wears  a  pelvic  belt  as  in  fracture. 

Dislocations  of  the  Femur  (Hip-joint). — These  injuries 
are  rare,  as  the  hip-joint  is  very  strong.  They  occur  in 
young  adults.     In  forcible  extension  the  head  of  the  femur 


462  MODERN  SURGERY. 

presses  against  the  capsule,  but  the  capsule  here  is  very- 
thick,  and  certain  muscles,  the  rectus,  psoas,  and  iliacus,  are 
pulled  tight  and  serve  to  strengthen  the  capsule.  The  head 
of  the  bone  cannot  go  directly  upward,  because  of  the  ace- 
tabulum (Edmund  Owen).  The  weak  point  of  the  acetabular 
rim  is  below ;  the  weak  part  of  the  capsule  is  also  below ; 
hence  forced  abduction  is  apt  to  take  the  head  of  the  bone 
through  the  lower  part  of  the  capsule,  a  dislocation  occur- 
ring primarily  into  the  thyroid  foramen.  The  signs  of  the 
dislocation  depend  upon  the  untorn  portion  of  the  capsule. 
The  Y-ligament  and  more  than  the  Y-ligament  usually 
escapes  laceration.  Vessels  are  rarely  injured.  Muscles  are 
often  torn.  In  some  cases  the  sciatic  nerve  is  lacerated, 
bruised,  or  caught  up  on  the  neck  of  the  bone.  Four  forms 
of  hip-joint  dislocation  exist :  (i)  upward  and  backward,  on 
the  dorsum  of  the  iHum;  (2)  backward,  into  the  sciatic 
notch ;  (3)  downward,  into  the  obturator  foramen ;  and  (4) 
inward,  on  the  pubes. 

All  dislocations  are  primarily  inward  or  outward.  From 
these  initial  positions  the  head  may  be  shifted  to  any  region 
about  the  socket  within  reach  of  the  remnant  of  untorn  cap- 
sule (Oscar  H.  Allis).  AlHs  would  reject  the  old  classi- 
fication.    He  would  suggest  the  following : 

Low  thyroid,      |     All  present  abduction  and 

-TT-  1  «  r  outward  rotation. 

High  j 

Reversed  thyroid  : 

IVTH^        "    '       I     ^^  present   adduction  and 

TT-  i"        „  i  inward  rotation. 

High  ) 

Dislocation  upon  the  dorsum  of  the  ilium  comprises  one- 
half  of  all  hip-dislocations.  It  is  caused  by  a  fall  or  a  blow 
when  the  limb  is  flexed  and  abducted  (as  in  carrying  a 
weight  upon  the  shoulder),  by  a  fall  upon  the  knees  or  feet, 
by  a  weight  striking  the  back  while  bending,  etc.  Allis  says 
rotation  inward  is  the  chief  element  in  its  production.  In 
this  dislocation  the  head  of  the  femur  goes  upward  and 
backward,  rests  upon  the  ilium,  and  is  always  above  the 
tendon  of  the  obturator  internus  muscle.  This  dislocation 
is  secondary  to  a  thyroid  dislocation,  because  of  muscular 
action  shifting  the  bone  from  its  initial  seat  of  displacement. 

Signs. — Dislocation  on  to  the  dorsum  of  the  ilium  is  indi- 
cated by  the  following  symptoms  :  the  buttock  looks  flat  and 
broad;  the  great  trochanter  is  above  Nelaton's  line  and  is 


DISEASES  AND   Ii\yUKIES   OF  BONES  AND  JOINTS.    463 


Fig.  119. — Hip- 
joint  dislocation  : 
upward,  or  on  the 
dorsum  of  the 
ilium  (Cooper). 


deeply  placed ;  the  head  of  the  bone  can  be  detected  in  its  new 
situation  ;  deep  pressure  in  front  of  the  joints  finds  a  hollow; 
the  leg  is  shortened  by  about  two  or  three  inches,  as  a  rule ; 
the  fascia  lata  is  relaxed ;  in  some  thin  people 
the  socket  can  be  outlined ;  when  the  patient  is 
recumbent  the  injured  extremity  can  be  brought 
to  the  perpendicular  without  flexing  the  leg 
(Allis) ;  the  knee  is  slightly  flexed  ;  the  thigh  is 
slightly  flexed,  inwardly  rotated,  and  adducted 
(Fig.  1 19),  this  is  shown  by  the  fact  that  the  axis 
of  the  thigh  of  the  injured  side,  if  prolonged, 
would  pass  through  the  lower  third  of  the  sound 
thigh) ;  when  the  capsule  is  extensively  lacerated 
there  may  be  no  adduction  and  may  be  eversion 
(Allis) ;  the  heel  is  raised,  and  the  great  toe  of 
the  foot  of  the  injured  side  rests  upon  the  front 
of  the  instep  or  the  ankle  of  the  sound  side ; 
rigidity  exists  ;  voluntary  movement  is  impossi- 
ble, though  some  passive  motion  is  possible  in 
the  direction  of  the  deformity  (the  deformity 
can  be  made  more  marked).  If  a  patient  is  recumbent  and 
the  knees  vertical,  the  foot  of  the  sound  extremity  is  free  of 
the  bed,  but  the  foot  of  the  injured  extremity  touches  the 
bed  (Allis's  sign). 

Diagnosis. — Examine  first  without  anesthesia,  and  then 
again  while  the  patient  is  anesthetized.  The  A'-rays  are 
valuable  in  diagnosis.  Dislocation  is  separated  from  intra- 
capsular fracture  by  noting  the  inversion,  the  great  shorten- 
ing, the  absence  of  crepitus,  the  age  of  the  subject,  and  the 
nature  of  the  force.  The  nature  of  the  force,  the  inversion, 
and  the  absence  of  crepitus  mark  the  diagnosis  from  extra- 
capsular fracture. 

Treatment. — The  chief  obstacle  to  reduction  in  dislocation 
on  to  the  dorsum  of  the  ilium,  Bigelow  states,  is  the  untorn 
portion  of  the  capsule,  especially  the  Y-ligament.  The  ilio- 
femoral, Y,  or  Bigelow's  ligament  resembles  an  inverted  Y, 
arises  from  the  anterior  inferior  spine  of  the  ilium,  is  inserted 
into  the  anterior  intertrochanteric  line,  and  is  incorporated 
into  the  front  of  the  capsule.  To  reduce  a  dislocation  this 
ligament  must  be  relaxed  by  manipulation  or  be  torn  by 
extension.  Manipulation  makes  the  head  of  the  bone  re- 
trace its  steps  over  the  same  route  it  took  in  emerging.  Give 
ether  ;  place  the  patient  supine  upon  a  mattress  on  the  floor  ; 
flex  the  leg  on  the  thigh  (to  relax  the  hamstrings),  the  thigh 
on  the  pelvis ;  increase  the  adduction  over  the  middle  line ; 


464 


MODERN  SURGERY. 


strongly  abduct ;  perform  external  rotation  and  extension. 
This  treatment  may  be  summed  up  as  flexion,  adduction, 
external  circumduction,  and  extension  ;  or,  as  Pick  puts  it, 
"  bend  up,  roll  out,  turn  out,  and  extend."  Allis's  advice  is  to 
fix  the  pelvis  to  the  floor,  lift  the  head  of  the  bone  to  the  level 
of  the  socket,  rotate  outward  by  carrying  the  leg  toward 
the  pubis,  and  extend  the  femur.  If  extension  and  counter- 
extension  are  employed,  make  extension  in  the  axis  of  the 
dislocated  limb  and  obtain  counter-extension  by  a  perineal 
band.  The  extension  band  is  fastened  to  the  thigh  by  a 
clove-hitch.  After  reduction  put  the  patient  to  bed  and  use 
sand-bags  (as  in  fracture  of  the  hip)  for  four  weeks.  We 
may  tie  the  knees  together  instead  of  using  the  sand-bags.. 
Passive  motion  is  made  in  the  third  week.  The  pulleys  must 
not  be  used  in  reduction.  They  may  inflict  great  or  even 
fatal  injury.  If  the  surgeon  fails  to  reduce  the  deformity, 
there  are  two  courses  open  to  him.  He  may  leave  it  alone. 
He  may  operate.  If  he  leaves  it  alone,  the  limb  will  become 
ankylosed,  though  probably  useful.  Allis  thinks  the  dorsal 
region  will  be  the  best  place  to  leave  it.  If  he  determines 
to  operate,  he  must  recognize  that  tenotomy  is  useless.  It 
is  necessary  to  make  a  free  incision  in  order  to  restore  the 
bone. 

Dislocation  into  the  Sciatic  Notch. — In  this  dislocation 
the  head  of  the  bone  passes  backward  and  a  little  upward, 
and  rests  upon  the  ischium  at  the  margin  of  the  sciatic 
notch  (not  in  the  notch),  below  the  tendon 
of  the  obturator  internus  muscle.  The 
causes  are  the  same  as  those  given  for  the 
previous  dislocation. 

Signs. — The  signs  in  dislocation  into  the 
sciatic  notch  are  like  those  of  dislocation  upon 
the  dorsum  of  the  ilium,  but  they  are  not  so 
marked.  There  are  flattening  and  broaden- 
ing of  the  hip  ;  ascent  of  the  trochanter 
above  Nekton's  line ;  shortening  to  the  ex- 
tent of  an  inch  ;  relaxation  of  the  fascia  lata. 
Allis's  sign  is  present,  that  is,  if  the  knee 
of  the  injured  side  is  vertical,  the  sole  of 
the  foot  touches  the  bed.  Flexion,  inward 
rotation,  and  adduction  exist,  but  the  axis 
of  the  femur  of  the  injured  side  passes 
through  the  knee  of  the  sound  side,  and 
the  ball  of  the  great  toe  of  the  injured  side  rests  upon  the 
great  toe  of  the  sound  side  (Fig.   120).      Other  symptoms 


Fig.  120. — Hip-joint 
dislocation:  back- 
ward, or  into  the  sci- 
atic notch  (Cooper). 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    465 

are  identical  with  those  of  dislocation  upon  the  dorsum  of 
the  ilium,  but  are  less  pronounced.  Allis's  signs  of  this 
dislocation  are  of  value :  if,  with  the  patient  recumbent,  the 
thighs  are  brought  to  a  right  angle  with  the  body,  shorten- 
ing on  the  affected  side  is  materially  increased ;  if  the  dislo- 
cated thigh  is  extended,  the  back  arches  as  in  hip  disease. 

Diagnosis  and  Treatment. — The  signs  of  dislocation  into 
the  sciatic  notch  are  similar  to,  but  are  less  marked  than, 
those  of  dorsal  dislocation,  and,  being  a  backward  disloca- 
tion, the  reduction  and  treatment  are  the  same  as  for  dis- 
location backward  upon  the  dorsum  of  the  ilium. 

Dislocation  Downward  into  the  Obturator  Foramen. — 
Downward  dislocation  is  the  primary  position  of  most  dislo- 
cations of  the  hip,  the  bone  rarely  remaining  in  the  thyroid 
foramen,  but  usually  mounting  up  as  a  result  of  muscular 
action  or  of  the  initial  violence.  The  cause  is  violent  abduc- 
tion by  falls  or  by  stepping  from  a  moving  car. 

Signs. — Dislocation  downward  into  the  obturator  foramen 
is  indicated  by  flattening  of  the  hip ;  the  head  of  the  bone 
is  felt  in  its  new  position  and  is  missed  from  the  acetabulum ; 
rigidity  exists ;  passive  motion  is  only  possible  in  the  direc- 
tion of  deformity,  and  that  to  a  slight  extent ;  a  hollow  is 
noted  over  the  great  trochanter,  which  process  is  well  below 
Nelaton's  line  and  nearer  than  normal  to  the  middle  line. 
There  is  a  depression  from  relaxed  muscles  and  fascia  noted 
between  the  ilium  and  femur.  The  gluteal  crease  is  lower 
than  is  the  crease  of  the  opposite  side ;  there  is  lengthening 
to  the  extent  of  one  to  two  inches ;  the  body  is  bent  forward 
by  the  traction  upon  the  psoas  and  iliacus  muscles,  and  is  also 
deviated  to  the  side,  thus  causing  great  apparent  lengthening  ; 
the  limb  is  advanced  partially  flexed  and  abducted,  and  the 
foot  is  pointed  straight  ahead  or  is  a  little  everted  (Fig.  121); 
when  the  patient  is  recumbent  extension  is  impossible,  the 
knees  cannot  be  pushed  together  without  great  pain,  and  the 
abductor  muscles  are  hard  and  rigid.  Allis's  sign  is  absent. 
Unreduced  dislocations  do  well,  the  patient  obtaining  a  very 
useful  hip-joint  (Sedillot). 

Treatment. — In  treating  dislocation  downward  into  the 
obturator  foramen  give  ether  and  effect  reduction  if  possible 
by  manipulation,  and,  if  this  fails,  by  extension.  To  reduce 
by  manipulation,  flex  the  leg  on  the  thigh  and  the  thigh 
on  the  pelvis,  and  then  perform,  in  the  following  order, 
abduction,  internal  circumduction,  and  extension.  Allis's 
rule  of  reduction  is  as  follows :  flex  the  pelvis  to  the  floor ; 
pull  the  head  outward  and  above  the  socket ;  fix  the  head ; 

30 


466 


MODERN  SURGERY. 


push  knee  toward  sound  knee  ;  extend  femur.  If  extension 
is  made,  make  traction  in  the  axis  of  the  hmb  by  means  of 
muslin  fastened  around  the  thigh  by  a  clove-hitch.  Do  not 
use  the  pulleys ;  operate  rather  than  use  them. 

Dislocation  upon  the  pubis  is  very  rare.     The  head  of 
the  bone  usually  rests  just  internal  to  the  anterior  inferior 


Fig.  121. — Hip-joint  dislocation :  down- 
ward into  the  obtutator  or  thyroid  fora- 
men (Cooper). 


Fig.  122. — Dislocation  on  the  pubis 
(Cooper). 


spine  of  the  ilium.  The  primary  position  of  the  bone  is  in 
the  thyroid  foramen ;  the  pubic  dislocation,  when  it  occurs, 
is  always  secondary,  and  is  due  to  the  initial  force  and  to 
muscular  action. 

Syinptoms. — In  pubic  dislocation  the  head  of  the  bone  can 
be  felt  and  seen  in  its  new  position ;  the  hip  is  flattened ; 
there  is  a  hollow  over  the  great  trochanter,  this  process 
being  found  below  the  anterior  superior  spine  of  the  ilium ; 
there  is  shortening  to  the  extent  of  an  inch ;  the  Hmb  is  in 
abduction  with  eversion  (Fig.  122),  and  the  knees  cannot  be 
approximated  without  great  pain.  When  the  knee  is  per- 
pendicular the  foot  of  the  injured  side  touches  the  foot  of 
the  bed. 

Treatment. — In  the  treatment  of  pubic  dislocation  give 
ether  and  employ  manipulation  as  for  thyroid  dislocation. 
If  this  fails,  employ  extension.  The  hmb  is  well  abducted, 
extension  is  made  downward  and  backward,  and  the  head 
of  the  femur  is  pulled  outward  "  by  a  towel  around  the  thigh, 
just  beneath  the  groin"  (Keetley).  The  after-treatment  is  the 
same  as  that  for  the  previous  forms. 

Anomalous  Dislocations  of  the  Hip. — In  supraspinous 
dislocation  the  dislocation  of  the  hip  is  backward,  the  head 


DISEASES  AND    INJURIES   OF  BONES  AND  JOINTS.    467 

of  the  femur  resting  upon  the  ilium  above  or  even  anterior 
to  the  anterior  superior  spine.  In  ischial  dislocation  the  dis- 
location is  downward  and  backward,  the  head  of  the  femur 
resting  on  the  ischial  tuberosity  or  in  the  lesser  sciatic  notch. 
Monteggid s  dislocation  is  a  supraspinous  dislocation  with 
eversion  of  the  limb.  In  perineal  dislocation  the  head  of  the 
femur  is  in  the  perineum.  In  suprapubic  dislocation  the  head 
of  the  femur  passes  above  the  pubes.  In  siibspinoiis  disloca- 
tion the  femoral  head  rests  on  the  horizontal  ramus  of  the 
pubes. 

Dislocation  with  Catching-  Up  of  Sciatic  Nerve  upon 
Reduction. — This  accident  causes  severe  pain.  The  leg  is 
flexed  on  the  thigh  and  the  thigh  is  flexed  on  the  pelvis. 
Allis  tells  us  that  the  task  of  reduction  is  very  unpromising. 
We  must  strive  to  put  the  neck  of  the  femur  in  such  a 
position  that  the  ner\'e  will  "  drop  off,"  and  yet  often  the 
nerve  cannot  drop  off  because  it  is  held  by  adhesion  to  the 
injured  muscles.  Allis  attempts  reduction  by  the  following 
plan : 

1.  Place  the  patient  upon  his  back  and  redislocate  the 
femur. 

2.  Extend  the  thigh. 

3.  Flex  the  leg  on  the  thigh. 

4.  Turn  ankle  out  until  the  leg  is  horizontal  (this  causes 
the  head  to  look  downward). 

5.  "  Shake,  shock,  jar,  adduct  and  abduct,"  to  disengage 
the  nerve. 

6.  Rotate  into  socket  without  flexing  the  leg  (without 
making  the  nerve  tense). 

7.  If  this  fails,  make  an  incision  above  the  popliteal  space, 
and  draw  the  nerve  out  of  the  wound.  Detach  the  head 
from  its  entanglement  and  rotate  it  into  the  socket. 

Dislocation  of  Head  of  Femur  -with  Fracture  of  Shaft. 
— We  may  incise  and  replace  and  wire  the  fragments.  We 
may  use  AIcBurney's  hooks  as  in  the  shoulder.  We  may 
be  forced  to  do  a  resection  of  the  head. 

Allis  maintains  that  it  is  possible  to  reduce  it  by  manipu- 
lation. He  states  that  the  upper  fragment  is  the  entire  lever, 
and  the  lower  fragment  "  is  only  the  agent  through  w'hich 
we  apply  our  force."  The  fragments  are  not  completely 
separated,  but  are  connected  at  one  side  by  material  which 
is  "  partly  periosteal,  partly  tendinous,  and  partly  muscular." 
This  connecting  material  enables  us  to  make  traction  upon 
the  upper  fragment,  but  does  not  allow  "  rotation,  circum- 
duction, and  leverage  through  the  agency  of  the  lower  frag- 


468  MODERN  SURGERY. 

ment."  Hence  "  the  only  agency  at  our  command  is  trac- 
tion." If  the  dislocation  is  inward  (forward),  draw  the  head 
outward  and  have  an  assistant  make  direct  pressure  upon 
the  head.  If  this  fails,  the  assistant  holds  the  head  to  pre- 
vent its  slipping  into  the  thyroid  depression,  and  the  surgeon 
makes  traction  inward  or  inward  and  downward.  If  the 
dislocation  is  outward  (backward),  make  traction  directly 
upward  to  lift  the  head  to  the  level  of  the  socket,  and  try  to 
place  the  head  over  the  socket  by  traction  obliquely  upward 
and  inward.  During  all  these  manipulations  an  assistant 
presses  upon  the  trochanter  to  prevent  the  head  slipping 
back.  Traction  is  now  made  downward  and  inward,  and  the 
tightened  ligament  drags  the  head  into  place. 

Dislocations  of  the  Knee. — These  dislocations  are  rare. 
There  are  four  forms — forward,  backward,  inward,  and  out- 
ward. They  may  be  complete  or  be  incomplete ;  the  com- 
monest dislocations  are  lateral.  The  cause  is  violent  force, 
such  as  a  fall,  or  in  jumping  from  a  moving  train,  or  in 
being  caught  by  the  foot  and  dragged. 

Dislocation  Forward  of  the  Knee-joint. — In  the  com- 
plete form  of  forward  dislocation  the  deformity  is  obvious. 
The  limb  is  usually  extended,  but  it  may  be  flexed.  Much 
shortening  exists  ;  the  condyles  are  felt  posterior  and  below  ; 
the  head  of  the  tibia  is  felt  anterior  and  above ;  the  patella  is 
movable  and  the  quadriceps  is  lax ;  pressure  of  the  condyles 
upon  the  contents  of  the  popliteal  space  arrests  the  tibial 
pulse  and  causes  edema  and  intense  pain.  In  incomplete 
dislocation  the  symptoms  are  identical  in  kind,  but  are  less 
pronounced. 

Treatment. — Compound  dislocation  of  the  knee-joint  often 
demands  excision. or  amputation.  In  simple  dislocation  give 
ether,  have  one  assistant  extend  the  leg  while  another  makes 
counter-extension  on  the  thigh,  and  the  surgeon  pushes  the 
bone  into  place.  Reduction  is  easy  because  of  hgamentous 
laceration.  Place  the  limb  on  a  double  incKned  plane,  and 
combat  inflammation  by  the  usual  methods  (see  Synovitis, 
page  406).  Begin  passive  motion  in  the  third  week.  The 
patient  must  wear  a  knee-support  for  months.  If  the  pop- 
liteal vessels  are  much  damaged,  gangrene  will  supervene 
and  amputation  will  be  demanded. 

Dislocation  Backward  of  the  Knee-joint. — In  the  com- 
plete form  of  knee-joint  dislocation  backward  displacement 
is  not  so  great  as  in  dislocation  forward.  The  head  of  the 
tibia  projects  posteriorly  and  above,  the  femoral  condyles 
anteriorly  and  below ;  the  leg  is,  as  a  rule,  partly  flexed, 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    aJo^ 

but  it  may  be  extended,  and  there  is  moderate  shortening. 
In  incomplete  dislocation  the  symptoms  are  less  marked. 

Treatment. — The  treatment  of  backward  dislocation  of  the 
knee-joint  is  the  same  as  for  forward  dislocation. 

Dislocation  Outward  of  the  E^ee-joint. — Is  usually  in- 
complete. The  inner  tuberosity  of  the  tibia  in  outward  dis- 
location lies  upon  the  outer  condyle  of  the  femur  (Pick) ;  the 
inner  condyle  of  the  femur  projects  internally ;  the  outer 
tibial  tuberosity  and  fibular  head  project  externally,  the  former 
having  a  depression  below  it,  and  the  latter  above  it ;  the  leg 
is  semiflexed,  but  shortening  is  absent. 

Dislocation  Inward  of  the  Knee-joint. — Is  usually  incom- 
plete. The  outer  tuberosity  of  the  tibia  in  inward  dislocation 
lies  upon  the  inner  condyle  of  the  femur ;  the  outer  condyle 
of  the  femur  forms  an  external  prominence,  and  the  inner 
tuberosity  of  the  tibia  forms  an  internal  prominence.  Pick 
cautions  us  not  to  mistake  a  separation  of  the  lower  femoral 
epiphysis  for  lateral  dislocation  (the  former  is  reduced  easily, 
the  deformity  tends  to  recur,  and  there  is  soft  crepitus). 

Treatment. — In  treating  lateral  dislocation  of  the  knee- 
joint,  effect  extension  and  counter-extension  as  in  antero- 
posterior dislocations.  The  leg  is  moved  from  side  to  side 
and  attempts  are  made  at  rotation.  The  after-treatment  is 
the  same  as  that  for  anteroposterior  luxations. 

Dislocations  of  the  Patella. — Are  usually  acquired. 
There  are  thirty-five  congenital  cases  on  record  (Bajardi). 
There  are  three  forms :  outward,  inward,  and  edgewise. 
The  so-called  dislocation  upward  is  in  reality  rupture  of  the 
ligamentum  patellae  (page  508). 

Dislocation  outward  may  be  due  to  muscular  action  or 
to  direct  force,  and  occurs  during  extension  of  the  leg.  It 
occasionally  happens  in  a  person  with  knock-knees.  If  the 
dislocation  is  complete,  the  bone  lies  upon  the  external  sur- 
face of  the  external  condyle ;  if  incomplete,  the  patella  rests 
upon  the  anterior  surface  of  the  external  condyle.  The  leg 
is  extended,  flexion  is  impossible,  and  attempts  at  flexion 
produce  great  agony.  The  knee  is  wider  than  normal. 
There  is  a  hollow  in  front  of  the  joint.  The  bone  is  felt 
in  its  new  position. 

Dislocation  inward  is  extremely  rare.  The  signs  of  this 
dislocation  are  like  the  signs  of  dislocation  outward,  except 
that  the  patella  rests  upon  the  inner  condyle. 

Treatment. — Give  ether.  Raise  the  body  upon  a  bed-rest, 
and  flex  the  thigh.  Grasp  the  patella,  depress  the  margin 
of  the  patella  which  is  farthest  from  the  center  of  the  joint 


470  MODERN  SURGERY. 

(Pick).  The  muscles  pull  the  bone  into  place.  Immobilize 
for  three  weeks,  when  passive  motion  is  begun. 

Dislocation  of  the  Patella  Edgewise. — The  patella  rotates 
vertically,  one  edge  resting  between  the  condyles.  As  a  rule, 
the  outer  border  is  in  the  intercondyloid  notch  (Pick).  This 
condition  is  produced  by  direct  force  when  the  extremity  is 
partly  flexed.  Twisting  and  muscular  action  have  been 
assigned  as  causes.     The  condition  is  obviously  manifest. 

Treatment. — Give  ether.  Pick  recommends  "  sudden  and 
forcible  bending  of  the  knee."  In  some  cases  the  bone  can 
be  pushed  into  place,  the  limb  being  extended  and  flexed  as 
in  the  reduction  of  a  lateral  dislocation.  In  some  cases 
incision  will  be  necessary. 

Dislocation  of  the  Semilunar  Cartilages  of  the  Knee 
(the  Internal  Derangement  of  Hey;  Subluxation  of  the 
Knee-joint). — These  interarticular  cartilages  are  attached 
in  front  of  and  behind  the  tibial  spine,  and  their  convexity 
is  attached  to  the  edge  of  the  tibial  tuberosities  by  the  coro- 
nary ligament.  The  inner  cartilage  is  connected  with  the 
internal  lateral  ligament,  and  it  has  a  moderate  freedom 
of  movement;  the  outer  cartilage  is  not  connected  with 
the  external  lateral  ligament,  and  is  not  freely  movable, 
yet  the  outer  is  more  often  dislocated  than  is  the  inner 
cartilage.  People  who  kneel  much  are  predisposed  to 
this  accident  (Annandale).  The  cause  is  a  twist  when  the 
knee  is  flexed,  as  in  stubbing  the  toe. 

Symptoms. — The  indications  of  interarticular-cartilage  dis- 
location are  a  sudden,  violent,  sickening  pain  in  the  knee, 
that  may  cause  the  patient  to  fall;  the  position  is  one  of 
fixed  semiflexion,  voluntary  motion  being  impossible  and 
passive  motion  causing  fierce  pain ;  a  displacement  of  either 
cartilage  away  from  the  tibial  spine  produces  a  prominence 
on  one  or  the  other  side  of  the  knee-joint,  and  a  displace- 
ment toward  the  tibial  spine  makes  a  prominence  on  one  side 
of  the  ligament  of  the  patella.  Subluxation  is  soon  followed 
by  inflammation  of  the  cartilages  and  of  the  joint,  and  swell- 
ing rapidly  masks  the  projection.  This  accident  is  usually 
mistaken  for  blocking  of  the  joint  by  a  floating  cartilage. 
One  point  in  diagnosis  is  that  a  loose  cartilage  changes  its 
position,  but  a  dislocated  cartilage  remains  always  in  the  same 
position  (Turner). 

Treatment. — In  treating  dislocation  of  the  semilunar  carti- 
lages of  the  knee  give  ether  and  reduce  by  forced  flexion  and 
sudden  extension  with  rotation,  at  the  same  time  endeavor- 
ing to  push  the  projecting  cartilage  into  place.     After  reduc- 


DISEASES  AND  INJURIES   OE  BONES  AND  JOINTS.    47 1 

tion  combat  inflammation,  apply  a  splint,  and  use  the  proper 
remedies  for  one  week  (see  Synovitis),  then  begin  passive 
motion.  As  recurrence  of  the  displacement  is  usual,  the 
patient  should  wear  a  knee-cap  for  a  year  or  more.  If 
reduction  is  impossible,  persistent  passive  motion  will  usu- 
ally secure  a  useful  joint.  In  intractable  cases  incise  and 
stitch  the  cartilages  or  remove  the  loosened  portion  (Annan- 
dale). 

Dislocations  of  the  Fibula  :  Dislocation  at  the  Supe- 
rior Tibiofibular  Articulation. — This  injury  is  rare.  The 
head  of  the  fibula  may  go  forward  or  backward.  The  causes 
are  direct  force  and  violent  adduction  of  the  foot  with  abduc- 
tion of  the  knee  (Bryant). 

Symptoms. — In  dislocation  of  the  fibula  the  position  is  one 
of  semiflexion,  voluntary  extension  and  flexion  being  impaired 
or  lost.  A  distinct  movable  projection  is  readily  noticed  in 
front  or  behind,  which  is  found  to  be  continuous  with  the 
fibula.  There  is  a  depression  over  the  normal  position  of  the 
head  of  the  fibula. 

Treatment. — In  treating  dislocation  of  the  fibula  bend  the 
knee  to  relax  the  biceps,  and  proceed  to  push  the  bone  into 
place.  Put  a  compress  over  the  head  of  the  fibula,  apply  a 
bandage,  and  put  the  limb  on  a  double  inclined  plane  for  three 
weeks.  At  the  end  of  this  time  put  a  lacing  knee-support 
upon  the  knee  and  let  the  patient  up.  Displacement  being 
liable  to  recur,  a  knee-cap  must  be  worn  for  a  year. 

Dislocations  of  the  Ankle-joint. — These  injuries  are  not 
unusual.  Fracture  is  a  frequent  complication.  There  are 
five  forms  of  ankle-joint  dislocation — outward,  inward,  for- 
ward, backward,  and  upward. 

Lateral  dislocations  of  the  ankle-joint  are  either  outward 
or  inward,  and  may  be  complete  or  incomplete.  In  these 
dislocations  the  astragalus  rotates.  In  incomplete  dislocations 
"  there  is  no  great  separation  of  the  trochlear  surface  of  the 
astragalus  from  the  under  surface  of  the  tibia,  but  the  outer 
or  inner  margin  of  this  surface  is  brought  into  contact  with 
the  articular  surface  of  the  tibia,  and  the  w^hole  foot  presents 
a  lateral  twist "  (Pick).  The  causes  of  these  dislocations  are 
twists  of  the  joint. 

Symptoms. — Incomplete  outward  dislocation  of  the  ankle- 
joint  is  known  as  Pott's  fracture  (see  page  402).  Complete 
outward  dislocation,  in  which  the  articular  surface  of  the 
astragalus  is  completely  displaced  outward  from  the  articular 
surface  of  the  tibia,  and  which  condition  is  associated  with  a 
fracture  of  the  fibula  and  separation  of  the  inferior  tibiofibu- 


472  MODERN  SURGERY. 

lar  articulation,  is  known  as  Dupuytr en' s  fracture.  In  incom- 
plete dislocation  the  foot  goes  outward  and  upward,  the  fibula 
is  fractured,  and  the  tibiofibular  ligaments  are  torn  off  In 
Dupuytren's  fracture  the  ankle  is  broad,  the  inner  malleolus 
projects  and  looks  lower  than  natural,  the  outer  malleolus 
ascends  with  the  foot,  the  foot  rotates  outward,  and  crepitus 
can  be  found.  In  inward  dislocation  which  is  associated  with 
fracture  of  the  inner  malleolus  there  is  inversion,  the  outer 
malleolus  projects,  and  crepitus  can  be  found.  In  incom- 
plete separation  the  symptoms  are  similar,  but  are  not  so 
marked. 

Treatment. — In  treating  a  case  of  dislocation  of  the  ankle- 
joint  the  deformity  is  reduced  by  flexing  the  leg  on  the  thigh 
and  the  thigh  on  the  pelvis ;  an  assistant  makes  counter-ex- 
tension from  the  knee  ;  the  surgeon  makes  extension  from  the 
foot,  and  at  the  same  time  rocks  the  astragalus  into  place. 
Dupuytren's  fracture  is  treated  in  the  same  manner  as  Pott's 
fracture  (page  402).  Dislocation  inward  is  treated  in  a  fract- 
ure-box for  the  same  period  as  Pott's  fracture. 

Anteroposterior  dislocations  of  the  ankleTJoint  are  rare. 
The  cause  is  the  catching  of  the  foot  in  jumping  or  falling — 
direct  violence.  In  dislocation  forward  the  foot  is  lengthened, 
the  heel  is  not  conspicuous,  the  tibia  and  fibula  project  against 
the  tendo  Achillis,  and  the  relation  of  the  malleoli  to  the 
tarsus  is  altered.  In  incomplete  dislocation  the  symptoms 
are  similar,  but  less  pronounced.  In  dislocation  backward 
the  foot  is  shortened,  the  tibia  and  fibula  project  in  front,  the 
heel  is  prominent,  and  the  relation  between  the  malleoli  and 
the  tarsus  is  altered.  In  incomplete  dislocation  the  symp- 
toms are  similar,  but  less  marked. 

Treatment. — In  anteroposterior  dislocation  of  the  ankle- 
joint,  reduce  as  in  lateral  dislocations.  Sometimes  the  tendo 
Achillis  must  be  cut.  Apply  a  silicate-of-sodium  dressing, 
and  let  it  be  worn  for  two  weeks  ;  then  begin  passive  motion, 
and  let  the  patiept  wear  side-splints  for  a  week  longer. 

Dislocation  upward  of  the  ankle-joint,  or  Nekton's 
dislocation,  is  a  very  rare  injury.  The  astragalus  is  wedged 
between  the  widely  separated  tibia  and  fibula.  This  dislo- 
cation is  usually  associated  with  fracture.  The  cause  is  a 
fall  upon  the  feet  from  a  great  height. 

Symptoms. — UpAvard  dislocation  of  the  ankle-joint  is  indi- 
cated by  the  widening  of  the  ankle  and  by  the  flattening  of 
the  foot.  The  malleoli  are  nearly  on  a  level  with  the  plantar 
surface  of  the  foot,  and  there  is  absolute  rigidity. 

Treatment. — In  treating  upward  dislocation  of  the  ankle- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    473 

joint  give  ether,  and  try  to  reduce  by  powerful  extension  and 
counter-extension.  Treat  the  injury  afterward  in  the  same 
manner  as  for  an  anteroposterior  luxation. 

Dislocation  of  the  Astragalus. — The  astragalus  may  be 
displaced  from  the  bones  of  the  leg  and  at  the  same  time  be 
separated  from  the  rest  of  the  tarsus.  The  displacement  may 
be  forward,  backward,  outward,  inward,  or  rotary. 

Dislocation  of  the  astragalus  forward  or  backward  is 
caused  by  falls  or  twists. 

Symptoms. — In  forward  dislocation  the  astragalus  projects 
strongly ;  there  is  shortening  of  the  foot,  and  the  malleoli 
approach  the  plantar  aspect  of  the  foot ;  the  foot  is  deviated 
to  one  side  or  to  the  other,  and  there  is  absolute  rigidity  of 
the  ankle-joint.  In  incomplete  luxations  the  symptoms  are 
similar,  but  less  marked.  This  dislocation  may  be  obliquely 
forward.  In  backward  dislocation  of  the  astragalus  the  foot 
is  not  deviated  to  either  side ;  the  astragalus  projects  between 
the  malleoli  and  above  the  os  calcis,  and  the  tendo  Achillis  is 
stretched  over  the  projection.  Rigidity  is  absolute.  This 
dislocation  may  be  obliquely  backward. 

Lateral  and  Rotary  Dislocations  of  the  Astragalus. — 
Lateral  dislocations  of  the  astragalus  are  rare,  are  always 
compound,  and  are  always  associated  with  fracture.  In  rotary 
dislocation  the  astragalus  remains  in  its  normal  habitat  after 
rotating  on  its  own  axis,  either  horizontal  or  vertical.  The 
causes  of  rotary  dislocation  are  twists  of  the  foot  when  it  is 
at  a  right  angle  to  the  leg  (Barwell).  The  symptoms  of  rotary 
dislocations  are  obscure.  There  is  rigidity,  but  sometimes 
portions  of  the  astragalus  may  be  made  out. 

Treatment  of  Dislocations  of  the  Astragalus. — In  treating 
astragalus  dislocation  reduce  under  ether  by  flexing  the 
knee  to  relax  the  gastrocnemius,  extending  the  foot,  and 
pushing  the  bone  into  place.  It  may  be  necessary  to  cut 
the  tendo  Achillis.  After  reduction  put  up  the  foot  and  leg 
in  silicate-of-sodium  dressing  for  two  weeks,  and  then  begin 
passive  motion  and  apply  side-splints,  which  are  to  be  worn 
for  one  week  more.  If  reduction  fails,  support  the  limb  on 
splints,  combat  inflammation,  and  endeavor  to  bring  about 
union  between  the  dislocated  bone  and  the  tissues.  Often, 
in  unreduced  dislocation,  the  skin  sloughs  over  the  project- 
ing bone.  Excision  is  demanded  the  moment  sloughing  is 
seen  to  be  inevitable.  Cases  of  compound  dislocation  of  the 
astragalus  require  immediate  excision. 

Subastragaloid  Dislocation. — This  condition  is  a  sepa- 
ration of  the   astragalus   from   the   os   calcis   and   scaphoid. 


474  MODERN  SURGERY. 

without  separation  of  the  astragalus  from  the  bones  of 
the  leg.  Pick  states  that  the  usual  classification  for  these 
dislocations  is  forward,  backward,  inward,  and  outward,  but 
that  the  displacement  is,  as  a  rule,  oblique,  the  foot  pass- 
ing backward  and  outward  or  backward  and  inward.  The 
causes  are  twists. 

Symptoms. — In  subastragaloid  dislocation  the  astragalus 
projects  on  the  dorsum ;  the  foot  is  everted  in  outward  dis- 
location and  inverted  in  inward  dislocation  ;  the  relation  of 
the  malleoli  to  the  astragalus  is  unaltered ;  the  ankle-joint  is 
not  absolutely  rigid ;  the  foot  "  is  shortened  in  front  and  is 
elongated  behind  "  (Pick). 

Treatment. — To  treat  subastragaloid  dislocation  make 
extension  in  the  direction  opposite  to  that  of  the  displace- 
ment. In  dislocation  of  the  tarsus  backward  fix  a  bandage 
around  the  foot,  on  a  level  with  the  heads  of  the  metatarsal 
bones,  which  bandage  the  surgeon  ties  around  his  shoulders. 
The  surgeon  puts  one  knee  in  front  of  the  angle  and  thus 
fixes  the  leg,  raises  himself  up  to  make  extension  upon  the 
tarsus,  and  moulds  the  bone  into  position.  Tenotomy  may 
be  necessary.  After  reduction  apply  a  silicate  dressing  for 
three  weeks.  The  ankle-joint,  fortunately,  is  not  involved, 
and  stiffness  of  this  articulation  need  not  be  apprehended. 
If  reduction  is  impossible,  take  the  same  course  as  in  luxa- 
tions of  the  astragalus. 

Dislocations  of  the  other  tarsal  bones  are  very  rare. 
Single  bones  may  be  dislocated,  or  the  luxation  may  occur 
at  the  mediotarsal  articulation. 

Symptoms  and  Treatment. — Projection  is  an  obvious 
symptom  in  dislocation  of  the  other  tarsal  bones.  The 
treatment  is  to  reduce  by  extension  and  moulding,  the  part 
being  put  up  in  silicate-of-sodium  dressing  for  two  weeks. 

Dislocations  of  the  metatarsal  bones  are  rare. 

Symptoms  and  Treatment. — Shortening  of  the  toes  and 
projection  of  the  dislocated  bone  are  symptoms  of  disloca- 
tion of  the  metatarsal  bones.  To  treat  these  dislocations 
reduce  by  extension  under  ether  and  put  up  in  a  silicate 
dressing  for  two  weeks.  If  reduction  fails,  the  functions  of 
the  foot  will  not  be  much  impaired. 

Dislocations  of  the  phalanges  are  very  rare.  The 
first  phalanx  of  the  big  toe  is  the  one  most  liable  to  dislo- 
cation. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges 
are  obvious.  The  treatmeiit  is  by  reduction  as  in  dislocations 
of  the  thumb.     Immobilize  for  two  weeks. 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.    475 


5.  Operations  upon  Bones. 

Osteotomy. — By  the  term  osteotomy  the  modern  surgeon 
means  Hterally  the  sectioning  of  a  bone  for  the  purpose  of 
straightening  a  Hmb  ankylosed  in  a  bad  position,  correcting 
a  bony  deformity,  or  amending  a  vicious  union  of  a  fracture. 
In  a  linear  osteotomy  the  bone  is  transversely  divided  in  one 
spot ;  in  a  cuneiform  osteotomy  a  wedge-shaped  portion  of 
bone  is  removed.  The  operation  of  osteotomy  may  be  per- 
formed with  a  saw  (Fig.  123)  or  with  an  osteotome.  The  saw 
creates  dust,  draws  much  air  into  the  wound,  and  lacerates 
the  tissues  to  a  considerable  degree.  Most  surgeons  prefer 
the  chisel  or  the  osteotome.  The  osteotome  slopes  down  to 
a  point  from  each  side  (Fig.  124) ;  the  chisel  is  straight  on  one 
side  and  on  the  other  is  bevelled  to  a  point. 

Osteotomy  for  Genu  Valgum,  or  Knock-knee  (Macewen's 
Operation,  Fig.  126). — In  this  operation  the  instruments  re- 


FiG.  124. — Osteotome. 


Fig.  125. — Rawhide  mallet. 


quired  are  the  scalpel,  hemostatic  forceps,  osteotomes  of  sev- 
eral sizes,  a  mallet  (Fig.  125),  and  a  sand-bag  wrapped  in  an 
aseptic  towel. 

Operation. — The  patient  lies  upon  his  back,  being  rolled  a 
little  toward  the  diseased  side.  The  leg  of  the  diseased  side  is 
partly  flexed  upon  the  thigh  and  the  thigh  upon  the  pelvis, 
and  the  extremity  is  laid  upon  its  outer  surface,  the  sand-bag 
being  pushed  between  the  extremity  and  the  bed,  opposite  to 
the  site  of  section.  The  flexion  of  the  knee  relaxes  the 
popliteal  vessels  and  saves  them  from  injury.  The  surgeon, 
if  operating  on  the  right  leg,  stands  outside  of  that  ex- 


476 


MODERN  SURGERY. 


tremity ;  if  operating  on  the  left  leg,  he  stands  opposite  the 
left  hip  (Barker).  Enter  the  knife  at  the  inner  side  of  the 
knee,  just  in  front  of  the  adductor  tubercle  of  the  inner  con- 
dyle and  on  a  level  with  the  upper  border  of  "  the  patellar 
articular  surface  of  the  femur"  (Barker) ;  cut  down  to  the 
bone,  and  make  an  incision  upward  one  inch  in  length,  in 
the  direction  of  the  axis  of  the 
femur.  At  the  lower  angle 
of  this  wound  insert  an  osteo- 
tome and  turn  it  to  a  right 


Fig.  126. — Osteotomj'  of  the  right 
femur  in  a  case  of  knock-knee  :  A  B, 
epiphyseal  line;  c,  section  of  Mac- 
ewen :  d  e,  section  of  Ogston. 


Fig.  127. — Macewen's  operation  for  genu  val- 
gum :  the  chisel  is  held  in  the  line  for  striking 
with  a  mallet ;  the  arrow  shows  the  direction  in 
which  the  chisel  is  levered  up  and  down  so  as  to 
make  a  wide  gap  in  the  bone  (after  Barker). 


angle  with  the  shaft,  half  an  inch  above  the  epiphysis  (Fig. 
1 26)  ;  strike  the  osteotome  several  times  with  a  mallet ;  move 
the  handle  several  times  toward  and  from  the  body,  so  as  to 
widen  the  cut  in  the  bone  (Fig.  127);  strike  the  osteotome 
again  several  times,  move  it  again,  and  continue  this  process 
until  the  bone  is  cut  one-third  through.  If  the  osteotome 
becomes  tightly  fixed,  withdraw  it  and  introduce  a  smaller 
one.  When  the  bone  is  cut  two-thirds  through  withdraw 
the  osteotome,  hold  a  piece  of  wet  antiseptic  gauze  over  the 
opening,  and  fracture  the  femur  by  strong  adduction.  Do 
not  suture  nor  drain  the  wound,  but  dress  it  antiseptically, 
wrap  the  entire  extremity  in  cotton,  and  apply  a  plaster-of- 
Paris  dressing  up  to  the  groin.  This  dressing  may  be  re- 
moved in  two  weeks,  and  the  patient  may  subsequently  be 
treated  with  sand-bags,  as  for  an  ordinary  fracture  of  the  thigh, 
but  without  extension.  This  operation  is  scarcely  ever  fatal. 
Ogston' s  Operation  (Fig.  1 26). — In  this  operation  the  inter- 
nal condyle  is  sawed  off  obliquely  with  an  Adams  saw — a 
proceeding  which  permits  the  straigthening  of  the  knee. 
The  objection  to  this  operation  is  that  it  opens  the  knee- 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.    477 

joint,  and  that  this  cavity  fills  up  more  or  less  with  a  mixture 
of  blood  and  bone-dust.  Macewen's  operation  is  decidedly 
the  safer. 

Osteotomy  for  a  Bent  Tibia. — In  this  operation  the  in- 
struments required  are  the  same  as  those  indicated  in  the 
above  operation.  The  tibia  is  divided  transversely  or 
obliquely  (linear  osteotomy),  or  a  wedge-shaped  piece  is 
removed  (cuneiform  osteotomy).  The  oblique  incision  is 
the  best.  If  the  convexity  of  the  tibial  curve  is  inward,  cut 
the  bone  from  above  downward  and  from  in  front  backward ; 
if  the  curve  is  forward,  section  the  bone  from  above  down- 
ward and  from  within  outward.  The  fibula  need  rarely  be 
interfered  with.  After  the  osteotomy  the  limb  is  treated 
just  as  it  would  be  for  an  ordinary  fracture. 

Osteotomy  for  Faulty  Ankylosis  of  the  Hip-joint. — 
This  operation  is  performed  in  order  to  allow  straightening 
of  a  limb  that  has  undergone  bony  ankylosis  in  a  faulty 
or  an  inconvenient  position.  In  some  cases  an  attempt  is 
made  to  obtain  a  movable  joint,  but  in  most  cases  the  sur- 
geon must  be  satisfied  with  an  ankylosis  in  extension.  Oste- 
otomy may  be  performed  through  the  neck  of  the  femur  or 
through  the  shaft  of  the  femur  below  the  trochanters. 

Osteotomy  through  the  neck  of  the  femur  is  performed 
(i)  with  a  saw  (Adams's  operation)  or  (2)  with  an  osteotome. 

I.  Adams's  Operation  (Fig.  128). — In  this  operation  the 
instruments  required  are  a  scalpel,  hemostatic  forceps,  a 
long,  blunt-pointed  tenotome,  and  an  Adams  saw. 

Operation. — The  patient  lies  upon  his  sound  hip ;  the  sur- 
geon stands  upon  the  side  to  be  operated  upon,  and  back 
of   the    patient.     The    knife   is    entered   a 
finger's  breadth  above  the  great  trochanter,  ky\\ 

is  pushed  in  until  it  strikes  the  neck  of  the  /^'^^'^""'^'■•^XJ 

bone,  is  then  carried  across  the  front  of  and  [  / 

at  a  right  angle  with  the  neck,  and  is  with-  /  \ 

drawn,   enlarging   the  wound   in    the    soft  \          / 

parts,  as   it  emerges,  to   the   extent  of  an 
inch.     The  saw  is  now  introduced  and  the 
neck  is  entirely  divided.     After  the  osteot- 
omy dress    the   wound    antiseptically    and 
place  the  extremity  straight.    To  straighten 
the  limb  it  may  be  found  necessary  to  cut      fig.  128— Osteotomy 
contracted     tendons     and     fascial     bands.     Ihe7et.r:^l.  Adams°s 
Apply  the  weight-extension  apparatus  and     operation'  ^'  ^^"''^ 
the  sand-bags.     Begin  passive  movements 
from  the  start  if  a  movable  joint  is  desired ;  few  patients  can 


478  MODERN  SURGERY. 

tolerate  the  pain  necessary  to  bring  this  about.  If  it  is 
determined  to  aim  for  a  stiff  joint,  treat  the  case  as  an  intra- 
capsular fracture  would  be  treated. 

2.  With  an  Osteotome. — The  instruments  required  in  this 
operation  are  the  same  as  those  used  for  genu  valgum.  No 
sand-bag  is  required.  The  position  of  the  patient  is  the  same 
as  that  in  Adams's  operation.  An  incision  one  inch  long  is 
made,  starting  just  above  the  great  trochanter,  ascending  in 
the  axis  of  the  femoral  neck,  and  reaching  to  the  bone.  An 
osteotome  is  introduced,  is  turned  to  a  right  angle  with  the 
bone,  and  is  struck  with  a  mallet  until  the  bone  is  completely 
divided.  (It  is  not  to  be  divided  partially  and  then  broken.) 
The  after-treatment  is  the  same  as  that  for  Adams's  opera- 
tion. The  operation  with  the  osteotome  is  to  be  preferred  to 
that  by  the  saw. 

Osteotomy  of  the  Shaft  of  the  Femur  below  the  Tro- 
chanters (Gant's  Operation). — In  this  operation  (Fig.  128) 
the  saw  may  be  used,  but  the  osteotome  is  to  be  preferred. 
The  instruments  employed  are  the  same  as  those  used  for 
Adams's  operation,  plus  an  osteotome. 

Operation. — The  position  in  Gant's  is  like  that  in  Adams's 
operation.  A  longitudinal  incision  one  inch  long  is  made 
upon  the  outer  aspect  of  the  femur  and  on  a  level  with  the 
lesser  trochanter.  The  osteotome  is  inserted  and  the  bone 
is  completely  divided  below  the  lesser  trochanter.  The 
after-treatment  is  the  same  as  that  for  Adams's  operation. 
Gant's  operation  is  the  best  method  for  correcting  faulty 
position  in  bony  ankylosis,  and  Adams's  operation  can  only 
be  employed  in  those  cases  where  the  femur  still  has  a  neck 
which  practically  is  unchanged. 

Osteotomy  for  Faulty  Ankylosis  of  the  Knee-joint. — 
This  operation  is  performed  for  bony  ankylosis  of  a  knee  in 
a  position  of  flexion.  The  instruments  employed  are  the 
same  as  those  used  for  genu  valgum. 

Operation. — The  patient  lies  upon  his  back  with  his  thighs 
flat  upon  the  bed,  the  legs  hanging  over  the  end  of  the  bed. 
The  surgeon  stands  on  the  patient's  right  side.  Just  above 
the  patellar  articular  surface  upon  the  femur  a  transverse 
incision  is  made,  one  inch  in  length  and  reaching  to  the 
bone.  The  osteotome  is  introduced  and  the  bone  is  cut 
nearly  through.  The  leg  is  then  forcibly  extended.  Do  not 
extend  too  violently,  or  the  popliteal  vessels  may  be  injured. 
In  cases  where  the  structures  of  the  popliteal  space  are 
tense,  do  not  at  once  bring  the  leg  into  extension,  but  do 
so  gradually  by  means  of  weights.     The  wound  is  dressed 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    479 

aseptically,  and  the  extremity  is  placed  upon  a  double  inclined 
plane  and  is  treated  as  for  fracture  near  the  knee-joint. 

Osteotomy  for  vicious  union  of  a  fracture  is  performed  in 
case  of  angular  deformity,  and  is  carried  out  in  the  same  man- 
ner as  are  the  above  procedures.  It  is  best,  when  possible,  to 
enter  the  osteotome  upon  the  concavity  of  the  bent  bone,  so 
that  the  periosteum  will  not  rupture  when  extension  is  made, 
and  the  patient  will  in  consequence  gain  a  longer  limb. 

Osteotomy  for  Hallux  Valgus. — In  this  operation  a  linear 
osteotomy  is  made  through  the  neck  of  the  metatarsal  bone 
of  the  great  toe,  the  toe  is  forcibly  adducted,  and  a  splint  is 
applied  to  the  inside  of  the  foot  and  the  toe. 

Osteotomy  for  Talipes  Bquinovarus. — The  instruments 
required  in  this  operation  are  a  scalpel,  hemostatic  forceps, 
a  narrow,  blunt-pointed  saw,  special  directors,  bone-cutting 
forceps,  sequestrum-forceps,  and  scissors. 

Operation  (after  Barker). — The  patient  lies  upon  his  back, 
the  thigh  is  semiflexed,  the  knee  is  bent,  and  the  sole  of  the 
foot  rests  upon  the  table.  The  surgeon  stands  to  the  right 
side  if  it  is  the  right  limb  to  be  operated  upon,  or  to  the  left 
side  if  it  is  the  left  limb.  Feel  for  the  outer  surface  of  the  cu- 
boid bone,  and  cut  away  from  over  the  latter  a  piece  of  skin 
corresponding  in  size  with  the  bone-wedge  intended  to  be 
removed  (this  piece  of  skin  must  include  the  bursa  which 
forms  in  these  cases).  Turn  the  foot  outward,  find  the 
astragaloscaphoid  articulation,  over  which  make  an  incision 
"  from  the  lower  to  the  upper  dorsal  border  of  the  scaphoid 
bone  "  (Barker),  reaching  through  the  skin  only ;  place  the 
foot  again  in  the  first  position,  raise  all  the  soft  parts  from 
off  the  superior  surface  of  the  tarsus,  and  clear  a  triangular 
surface  corresponding  with  the  base  of  the  wedge  to  be 
removed;  pass  a  "kite-shaped"  director  (Fig.  129)  into  the 
external  wound,  and  cause  it  to  project  from  the  internal 
wound ;  push  the  saw  through  the  groove  of  the  director 
nearest  the  toes,  and  saw  through  the  tarsus,  from  the  dor- 
sum to  the  sole,  at  right  angles 
to  the  metatarsal  bones ;  push 
the  saw  through  the  groove  of 
the  director  nearest  the  ankle, 
and  saw  from  the  dorsum  to  the 

sole,  at    right    angles    to  the   long  Fig.  i29.-Davy's  director  (Pyer 

axis  of  the  calcaneum  ;  grasp  the 

wedge-shaped  piece  of  bone  with  sequestrum-forceps,  and 
cut  it  out  with  scissors,  with  bone-forceps,  or  with  a  blunt 
bistoury.     The  wound  is  well  irrigated,  the  foot  is  straight- 


48o 


MODERN  SURGERY. 


ened,  the  internal  wound  is  sewed  up,  the  external  wound  is 
sutured  except  at  its  lowest  portion,  where  a  drainage-tube 
is  to  be  retained  for  twenty-four  hours,  and  the  wound  is 
dressed  antiseptically.  The  foot  is  put  up  in  plaster  or  is  put 
upon  a  Davy  spHnt. 

Osteotomy  for  Talipes  Equinus. — This  operation  is  de- 
scribed by  Mr.  Davy,  who  devised  it,  as  follows :  ^  "  Taking 
the  line  of  the  transverse  tarsal  joint  as  a  guide,  on  the  outer 
and  inner  sides  of  the  foot,  and  immediately  over  the  joint, 
two  wedge-shaped  pieces  of  skin  are  removed,  equal  in  extent 
to-  the  amount  of  bone  demanded.  The  soft  structures  are 
freed  on  the  dorsum  of  the  foot  in  the  way  previously 
described ;  but,  as  the  base  of  the  osseous  wedge  for 
equinus  cases  is  at  the  dorsum  and  its  apex  at  the  sole,  the 
parallel  wire  director,  instead  of  the  kite-shaped  varus  one, 
is  used.  The  saw  is  successively  inserted  in  its  grooves, 
and  by  keeping  in  mind  the  idea  of  a  keystone  a  clean 
wedge  of  bone  is  cut  out  from  the  dorsum  to  the  sole  of 
the  foot."  The  wedge  is  extracted,  and  the  foot  is  straight- 
ened and  is  put  in  plaster  or  in  a  Davy  spHnt. 

Operative  Treatment  of  Recent  Fractures. — In  recent 
fractures  where  reduction  is  impossible  or  where  displace- 
ment recurs  in  spite  of  splints,  it  may  be  advisable  to  oper- 
ate. In  such  cases  a  skiagraph  should  always  be  taken, 
and  it  will  often  decide  whether  operation  is  or  is  not  indi- 
cated. In  most  instances  of  irreducible  fracture  reduction 
of  the  fragments  is  impossible  because  of  muscle  or  fascia 
caught  between  them  or  because  of  hardening  and  shorten- 
ing of  periosteal  soft  parts,  due  to  hemorrhage  and  inflam- 


FiG.  130. — Bone  ferrules  (Senn). 

mation.  In  such  cases  it  may  be  necessary  to  make  a 
tolerably  long  incision ;  the  ends  of  the  fragments  are  loos- 
ened from  their  anchorage,  the  inflammatory  ties  are  cut, 
tissue  is  removed  from  between  the  fragments,  and  if  the 
ends  are  very  irregular  they  are  sawn  off  evenly. 

1  Barker's  Manual  of  Surgical  Operations. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    48 1 

The  fragments  are  bored  and  brought  together,  and  are  held 
by  silver  wire  or  kangaroo-tendon,  or  both  fragments  are  sur- 
rounded by  Senn's  bone  ferrule,  and  fixation  is  thus  secured 
(Figs.  130,  131).     Drainage  is  unnecessary,  the  soft  parts  are 


Fig.  131. — Bone  ring  and  ferrule  applied  (Senn). 

sutured  and  dressed  with  sterile  gauze,  and  the  extremity  is 
put  up  in  plaster.  If  the  clavicle  is  operated  upon,  after 
sterile  dressings  are  applied  a  Velpeau  bandage  is  put  on, 
and  the  turns  of  this  bandage  are  overlaid  with  plaster-of- 
Paris,  a  trap-door  being  cut  over  the  seat  of  operation.  In 
such  operations  the  author  does  not  use  an  Esmarch  band- 
age, as  he  believes  it  best  to  see  what  is  cut  and  thoroughly 
arrest  bleeding  at  the  time,  rather  than  run  the  danger  of 
oozing  and  infection. 

The  author  has  wired  recent  fractures  of  the  humerus, 
tibia,  femur,  and  clavicle.  Arbuthnot  Lane  believes  that 
every  very  oblique  fracture  of  the  tibia  and  fibula  low  down 
should  be  treated  by  incision  and  fixation.'  It  is  necessary 
to  bear  in  mind  that  if  one  of  two  parallel  lines  is  broken  (as 
the  radius  alone  or  tibia  alone),  and  it  is  found  necessary  to 
resect  a  considerable  portion,  a  like  amount  should  be  re- 
sected from  the  companion  bone  in  order  to  prevent  great 
deformity. 

Recent  Transverse  Fracture  of  the  Patella  (see  page 
397). 


1  Brit.    Med.  Jour.,  April  20,  1895. 


»1 


482 


MODERN  SURGERY. 


Bone -grafting,  or  Transplantation  (see  page  316). 
Operative  Treatment  of  Ununited  Fracture.^The 

instruments  required  in  this  operation  are  a  scalpel,  hemo- 
static forceps,  dissecting-forceps,  retractors,  Allis's  dissector, 


Fig.  132.  — Hamilton's  improved  bone-drills. 


Fig.  133. — Brainard's  drills  with  Wyeth's  adjustable  handles. 

an  awl  or  special  drill  (Figs.  132,  133),  chisels,  a  mallet,  a  iine 
saw,  lion-jaw  forceps,  and  silver  wire. 

In  operating,  incise  longitudinally  down  to  the  seat  of 
fracture,  retract  the  periosteum  from  the  bone,  drill  the  bones 
before  cutting  them,  chisel  away  the  material  of  imperfect 
union,  saw  through  each  end  far  enough  from  the  seat  of 
fracture  to  reach  sound  tissue,  pass  large  silver  wires  through 
the  holes  (this  wire  should  be  one-tenth  inch  in  diameter  for 
the  femur,  one-sixteenth  inch  for  the  patella,  etc.)  (Fig.  1 34), 


Fig.  134. — Wiring  of  bones  for  ununited  fracture  :  aa,  sawn  surfaces  approximated  after 
removal  of  old  material  which  was  interposed  between  the  fragments;  (53,  (5<5,  perforations 
drilled  completely  across  the  bone ;  cc,  wires  ready  for  twisting. 


twist  the  wires  a  fixed  number  of  times  (two  complete  turns) 
in  the  direction  that  the  hands  of  a  watch  move  (this  is 
Keen's  direction  in  case  removal  of  the  wires   should  be 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    483 


demanded),  sever  the  ends  of  the  wires,  and  hammer  their 
stems  against  the  bone.  The  wires  may  never  require  re- 
moval. Dress  the  part  as  a  recent  fracture.  Various  plans 
besides  wiring  have  been  employed  in  ununited  fracture. 
Gussenbauer's  clamp  is  used  by  some.  Menard  and  Lanne- 
longue  inject  a  i  :  10  solution  of  chlorid  of  zinc  between  the 
fragments  and  around  their  ends,  and  then  immobilize  the 
parts.  Some  surgeons  unite  the  fragments  with  kangaroo- 
tendon  instead  of  wire  (suturing  of  bone) ;  others  use  nails 
of  bone  or  ivory ;  others  use  screws.  Senn  asserts  that  the 
above  methods  will  not  hold  fragments  in  contact  if  these 
fragments  have  a  tendency  to  become  displaced.  Senn 
fastens  the  bones  together  by  hollow  cylinders  of  decalcified 
bone  or  ivory,  the  cylinders  being  perforated  in  many  places 
(bone  ferrules)  (Fig.  1 30).  The  soft  parts  are  sutured,  no 
drain  is  used,  and  the  limb  is  encased  in  plaster. 

Ununited  Fracture  of  Patella. — An  incision  is  made  in 
the  long  axis  of  the  limb,  over  the  middle  of  the  space 
between  the  fragments,  from  well 
above  the  upper  fragment  to  well 
below  the  lower  piece ;  this  in- 
cision divides  all  the  soft  parts. 
The  soft  parts  are  retracted, 
but  the  periosteum  is  undis- 
turbed ;  each  fragment  is  bored 
(Fig.  135,  i)  in  one  or  two 
places ;  the  surfaces  of  the  frag- 
ments are  cut  square  through 
sound  bone  with  a  saw ;  all  old 
reparative  material  is  cut  away ; 
the  wires  are  passed  through  the 
perforations,  twisted,  cut  off,  and 
hammered  down  as  before  (Fig. 
135,  2).  If  the  ends  cannot  be 
approximated,  it  may  become  nec- 
essary to  incise  the  muscle  around 
and  above  the  patella  or  to  partially  separate  the  tuberosity 
of  the  tibia  and  bend  this  process  upward.  A  small  drain 
is  inserted  above  the  bone,  the  wound  is  sutured,  aseptic 
dressings  are  applied,  and  the  limb  is  put  upon  a  Macewen 
splint. 

Treves' s  Operation  for  Caries  of  the  I/Umbar  and 
I/ast  Dorsal  Vertebrae. — In  this  operation  the  right  loin 
is  chosen  for  incision,  as  a  rule.  The  instruments  required 
are  a  scalpel,  hemostatic  forceps,  grooved  director,  an  Allis 


Fig.  135. — Wiring  of  the  patella  :  i, 
fragments  cut  and  cleaned  and  the 
wires  passed ;  2,  wires  twisted  and 
hammered  down  upon  the  bone  (after 
Barker). 


484 


MODERN  SURGERY. 


dissector,  sequestrum-forceps,  curet  spoons,  and  a  sand 
bag. 

Operation. — The  patient  lies  upon  his  left  side,  with  the 
knees  drawn  up  and  a  sand  bag  under  him.  The  surgeon 
stands  behind  the  patient  (Barker).  An  incision  is  made  at 
the  outer  border  of  the  erector  spinae  mass,  reaching  from 
the  last  rib  to  the  iliac  crest  and  going  down  at  once  to  the 
lumbar  fascia.  The  lumbar  aponeurosis  is  opened,  the  erector 
spinae  is  retracted  inward,  and  the  anterior  portion  of  the 
erector  spinae  sheath  is  incised.  The  quadratus  lumborum 
muscle  is  next  cut,  and  then  the  anterior  leaflet  of  the  lumbar 
aponeurosis  is  slit.  Loose  pieces  of  bone  are  removed  with 
forceps,  and  cavities  are  thoroughly  curetted.  The  Avound 
is  irrigated  with  corrosive  sublimate  and  is  dusted  with  iodo- 
form ;  a  large  tube  is  inserted ;  the  wound  is  packed  with 
iodoform  gauze,  is  partly  closed  by  sutures  of  silkworm  gut, 
and  is  dressed  antiseptically. 

Aspiration  of  Joints. — In  certain  cases  of  joint-effusion 
from  inflammation,  tubercular  or  otherwise,  and  sometimes 
in  hemorrhage  into  a  joint,  it  is  desirable  to  remove  the  fluid 
by  aspiration.     The  pneumatic  aspirator  is  used  (Fig.  136). 


Fig.  136. — Aspirator  and  injector. 


The  trocar  and  cannula  are  thoroughly  asepticized  and  the 
joint  is  prepared  as  for  a  set  operation.  The  needle  is  entered 
at  a  surface  free  from  vessels.  The  directions  for  using  an 
aspirator  are  as  follows :  insert  the  stopper  firmly  into  a 
strong  bottle  (a  clear  glass  one  preferred),  then  attach  the 
short  elastic  hose  to  the  stopcock  B  of  the  tube  projecting 
from  the  stopper,  and  attach  the  other  end  of  the  same  elastic 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.    485 

hose  to  the  exhausting  or  inward-flowing  chamber  of  the 
pump.  Next  attach  one  end  of  the  longer  elastic  hose  to 
the  stopcock  A  projecting  from  the  stopper,  and  the  other 
end  to  the  needle.  Care  should  be  taken  that  all  the  fittings 
or  attachments  are  placed  firmly  into  their  respective  places. 
Now  close  the  stopcock  A  and  open  stopcock  B,  and  by 
giving  from  thirty-five  to  fifty  strokes  of  the  pump  a  suffi- 
cient vacuum  can  be  produced  to  fill  with  the  fluid  from  the 
joint  a  bottle  holding  from  a  pint  to  a  quart.  After  having 
formed  the  vacuum,  close  the  stopcock  B,  and  the  instru- 
ment is  for  use.  The  trocar  may  be  used  to  inject  antiseptic 
agents  into  the  part.  The  part  is  dressed  antiseptically  and 
is  put  at  rest  upon  splints. 

Bxcisions  of  Bones  and  Joints. — Excision  or  resec- 
tion of  a  joint  is  the  removal  of  the  articular  portions  of  the 
bones  of  the  joint,  and  also  the  cartilage  and  synovial  mem- 
brane. In  the  hip-joint  and  shoulder-joint  the  head  of  the 
long  bone  only  may  be  removed,  and  not  the  articular  sur- 
faces of  both  bones.  In  excision  enough  bone  is  known  to 
have  been  removed  only  when  the  remaining  bone  bleeds. 
Excision  of  a  bone  .is  the  removal  of  an  entire  bone  or  of  a 
portion  of  it.  Excision  is  a  conservative  operation  which 
often  averts  amputation. 

Excision  may  be  performed  by  the  open  method,  in  which 
the  periosteum  is  not  preserved,  or  it  may  be  performed  by 
the  subperiosteal  method,  in  which  the  periosteum  is  carefully 
separated  by  a  rugine  and  the  capsular  ligament  is  preserved. 
Artlirectoiny,  or  evasion,  is  the  excision  of  the  diseased  syno- 
vial membrane  and  ligament,  and  also  small  foci  of  disease 
of  bone  and  cartilage. 

Excision  may  be  employed  for  compound  dislocation,  and 
in  compound  dislocations  of  the  elbow  and  the  shoulder  it  is 
usually  performed.  Excisions  for  compound  dislocations  in 
other  large  joints  are  very  dangerous ;  they  are  rarely  at- 
tempted in  battle-field  practice,  and  are  to  be  avoided  even  in 
civil  practice  unless  the  patient  is  young  and  vigorous  and 
every  advantage  can  be  given  him  during  the  operation  and 
convalescence.  Excision  for  deformity  is  rarely  performed 
except  upon  the  hip,  the  knee,  and  the  shoulder,  and  these  ex- 
cisions must  not  be  employed  if  the  patient's  condition  leads 
one  to  fear  the  result  of  a  protracted  convalescence.  Ex- 
cision of  the  elbow,  however,  is  usually  a  safe  operation.  In 
excising  for  deformity  always  consider  the  patient's  trade  and 
the  demands  of  habitual  position  which  it  makes  upon  him.^ 
^  Joseph  Bell,  in  his  Manual  of  Surgical  Operations. 


486  MODERN  SURGERY. 

Excision  is  largely  employed  for  joint-disease,  especially 
for  tubercular  joints.  Bell  states  that  attempts  to  preserve 
the  limb  without  excision  are  more  largely  justifiable  in  the 
lower  than  in  the  upper  limbs,  because  operation  in  the  lower 
extremity  is  more  dangerous  than  in  the  upper,  and  because 
a  cure  without  operation  in  the  lower  limbs,  if  this  cure  can  be 
brought  about,  gives  as  good  a  result  as  a  cure  by  excision. 
In  the  upper  extremities  the  danger  from  operation  is  less 
than  is  the  danger  from  waiting.  In  a  young  subject  an  ex- 
cision may  remove  the  epiphysis,  and  thus  lead  to  permanent 
shortening,  which  is  productive  of  less  inconvenience  and  de- 
formity in  the  arm  than  in  the  leg.  The  great  danger  of  ex- 
cision operations  is  that  the  section  may  be  made  through 
cancellous  bony  tissue ;  hence  suppuration,  phlebitis,  myelitis, 
septicemia,  or  pyemia  may  follow  ;  further,  in  excision  the  cut 
is  through  diseased  tissue,  and  a  protracted  convalescence  is 
often  inevitable.  Amputation  is  effected  through  healthy 
tissue,  and  the  convalescence  is  short.  Excision,  however, 
when  successful,  gives  the  patient  a  very  useful  limb. 

Brasion,  or  Arthrectomy. — Erasion  is  the  complete  re- 
moval of  diseased  synovial  membrane,  ligaments,  etc.  This 
operation  seeks  to  remove  a  depot  of  infection  in  an  early 
stage  of  tubercular  synovitis,  and  it  possesses  the  conspicu- 
ous merit  of  not  interfering  with  the  epiphysis.  Erasion  is 
oftenest  practised  upon  the  knee-joint.  The  instruments 
required  are  a  scalpel,  hemostatic  forceps,  dissecting-forceps, 
toothed  forceps,  volsellum,  scissors,  bone-gouges,  curets,  and 
an  Esmarch  apparatus. 

Erasion  of  the  Kjiee-joint. — The  patient  lies  upon  his  back ; 
the  limb  is  flexed  with  the  sole  of  the  foot  planted  upon  the 
table,  and  an  Esmarch  bandage  is  applied  at  a  point  well  up 
on  the  thigh.  The  surgeon  stands  to  the  right  of  the  patient. 
The  incision  starts  in  the  mid-line  of  the  thigh  (on  the  side 
opposite  to  that  occupied  by  the  surgeon),  about  three  inches 
above  the  patella ;  it  is  carried  down  across  the  ligament  of 
the  patella  and  up  to  a  corresponding  point  on  the  opposite 
side  of  the  thigh.  This  incision  is  made  down  to  the  bone ; 
the  flap  is  turned  up  and  the  joint  exposed ;  the  knee-joint  is 
strongly  flexed,  and  the  synovial  membrane  and  diseased 
Hgaments  are  dissected  away  with  scissors  and  forceps,  great 
care  being  taken  that  the  posterior  ligaments  (which,  fortu- 
nately, are  rarely  implicated  early  in  the  case)  are  not  divided 
and  that  the  contents  of  the  popliteal  space  remain  intact. 
After  removing  the  diseased  ligaments  and  synovial  mem- 
brane examine  the  cartilage  and  remove  any  diseased  por- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    487 


tion,  and  then  examine  the  bone  and  gouge  away  any  tuber- 
cular foci.  Ligate  any  exposed  vessels,  irrigate  the  wound 
and  dust  with  iodoform,  straighten  the  extremity,  suture  to- 
gether the  ends  of  the  ligamentum  patellae,  suture  the  skin 
after  inserting  a  drainage-tube  in  each  angle,  dust  iodoform 
over  the  wound,  and  dress  antiseptically.  Put  the  limb  upon 
a  posterior  splint  for  a  few  days,  then  take  out  the  drainage- 
tubes,  re-dress  antiseptically,  and  put  up  in  a  plaster-of-Paris 
cast,  cutting  trap-doors  upon  each  side  and  keeping  the 
joint  immobile  for  two  or  three  weeks.     This  operation  is 

Fig.  137. 


Fig.  138. 


Fig.  137.— i-io.  Amputations  (Joseph  Bell):  i,  of  lower  third  of  forearm  (Teale's); 
2,  at  shoulder-joint  by  large  postero-external  flap  (second  method)  ;  3,  at  shoulder-joint  by 
triangular  flap  from  deltoid  (third  method)  ;  4,  5,  through  tarsus  (Chopart's):  6,  7,  at  knee- 
joint  ;  8,  by  single  flap  (Garden's) ;  9,  10,  of  thigh  (Teale's).  A,  excision  of  hip  ;  B,  of  ankle- 
joint  (Hancock's  incision). 

Fig.  138.— 1-18,  Amputations  (Joseph  Bell):  i,  amputation  at  wrist-joint  (dorsal  in- 
cision): 2,  at  wrist-joint  (palmar  incision);  3,  at  forearm  (dorsal  incision);  4,  at  forearm 
(palmar  incision)  ;  5,  at  elbow-joint  (anterior  flap)  ;  6,  at  arm  (Teale's) ;  7,  at  shoulder-joint 
(first  method);  8,  9,  of  metatarsus  (Hey's)  ;  10,  11,  at  ankle  (Syme's)  ;  12,  13,  of  leg,  pos- 
terior flap  (Lee's);  14,  at  knee-joint  (Garden's);  15.  of  thigh  (B.  Bell's);  16,  of  thigh 
(Spence',s)  ;  17,  of  thigh  in  middle  third;  18,  at  hip-joint.  A,  excision  of  wrist  (radial  in- 
cision); E,  of  wrist  (ulnar  incision). 

only  suited  to  early  cases  in  which  the  lesion  involves  chiefly 
or  purely  the  synovial  membrane  and  ligaments,  and  in  these 
cases  it  frequently  gives  a  good  result,  some  capacity  for 
motion  being  not  unusually  preserved. 

Excision  of  the  Shoulder-joint. — In  the  shoulder-joint 


488 


MODERN  SURGERY. 


partial  excision  is  often  performed,  the  head  of  the  humerus 
being  removed  and  the  glenoid  being  undisturbed ;  but  some 
patients  require  complete  excision,  the  entire  glenoid  depres- 
sion, as  well  as  the  head  of  the  humerus,  being  removed  by 
the  surgeon.  Excision  of  the  shoulder-joint  is  made,  if 
possible,    an    intracapsular   operation,    the    capsule    being 


Fig.  139. 


Fig.  140. 


Fig.  139. — 1-9,  Amputations  (Joseph  Bell)  :  i,  of  arm  by  double  flaps;  2,  at  shoulder- 
joint;  3,  at  ankle-joint  by  internal  flap  (Mackenzie's)  ;  4,  5,  of  leg  just  above  the  ankle-joint 
(Syme's)  ;  6,  7,  below  the  knee  (modified  circular) ;  8,  through  condyles  of  femur  (Byrne's); 
p,  at  lower  third  of  thigh  (Syme's).  a,  excision  of  head  of  humerus  ;  b,  of  knee-joint  (semi- 
lunar incision). 

Fig.  140. — 1-8,  Amputations  (Joseph  Bell) :  i,  at  elbow-joint  (posterior  flap) ;  2,  at  shoul- 
der-joint, posterior  incision  (first  method)  ;  3,  at  ankle-joint  (Mackenzie's)  ;  4,  through  con- 
dyles of  femur  (Syme's)  ;  5,  at  lower  third  of  thigh  (Syme's)  ;  6,  at  knee  (posterior  incision) ; 
7,  of  thigh  (Spencer's);  8,  at  hip-joint,  a-g,  Excisions;  A,  excision  of  shoulder-joint  (deltoid 
flap)  ;  B,  of  shoulder-joint  (posterior  incision)  ;  c,  of  elbow-joint  (H-shaped  incision);  D,  of 
elbow-joint  (linear  incision)  ;  E,  of  hip-joint  (Gross's)  ;  F,  of  os  calcis  ;  G,  of  scapula. 

opened,  but  the  capsular  attachment  to  the  anatomical 
neck  not  being  interfered  with.  In  bad  cases,  however,  the 
capsular  attachment  must  be  destroyed.  This  operation  is 
rare  in  civil,  but  is  common  in  military  practice ;  it  is  per- 
formed in  gunshot-wounds,  in  compound  dislocations,  in 
tubercular  disease,  and  in  tumors  of  the  head  and  upper  por- 
tion of  the  humerus.  The  instruments  required  are  a  scalpel, 
an  Adams  saw,  an  osteotome  or  chisel,  a  mallet,  an  Allis 
dissector,  a  periosteum-elevator,  hemostatic  forceps,  dissect- 
ing-forceps,  toothed  forceps,  lion-jawed  forceps,  sequestrum- 
forceps,  metal  retractors,   curets,  and  cutting  bone-forceps. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    489 

Operation  by  Anterior  Incision. — The  patient  lies  supine ; 
a  pillow  is  placed  beneath  the  shoulders,  and  a  sand  pillow 
is  put  beneath  the  shoulder  to  be  operated  upon.  The  arm 
is  held  to  the  side  with  the  outer  condyle  forward  and  the 
bicipital  groove  inward  (Barker's  directions).  The  surgeon 
stands  by  the  affected  side.  An  incision  three  or  four 
inches  in  length  is  made  from  just  external  to  the  cora- 
coid  process,  running  straight  down  the  humerus  (Fig. 
139,  a).  This  incision  divides  the  border  of  the  deltoid 
muscle  and  brings  into  sight  the  long  head  of  the  biceps. 
The  tendon  of  the  biceps  is  retracted  inward,  unless  it  is  dis- 
eased, in  which  case  it  is  resected.  The  knife  is  carried  up 
the  groove  and  opens  the  capsule  of  the  joint.  The  peri- 
osteum is  lifted  from  the  neck  of  the  bone  while  an  assistant 
rotates  the  elbow  to  make  the  muscles  tense.  In  some 
places,  if  the  periosteum  tears,  muscular  insertions  must  be 
cut  with  a  knife.  The  head  of  the  bone  is  sawn  off  while 
the  bone  is  in  place,  or  the  elbow  is  strongly  pulled  back,  and 
the  head  of  the  bone  is  forced  out  of  the  wound,  and  is  then 
sawn  off  at  the  point  required.  In  ordinary  cases  remove 
only  the  articular  head ;  in  other  cases  make  the  section  just 
above  the  surgical  neck ;  in  yet  others  remove  a  portion  of 
the  shaft.  If  the  glenoid  cavity  is  found  slightly  diseased, 
any  dead  bone  must  be  removed  by  the  chisel  and  mallet 
or  b\'  the  cutting-forceps.  If  the  cavity  is  seriously  diseased, 
the  entire  glenoid  should  be  removed.  Scrape  away  all  dam- 
aged tissue  ;  ligate  bleeding  points  ;  irrigate  the  wound  with 
corrosive-sublimate  solution  ;  swab  it  out  with  a  solution  of 
chlorid  of  zinc  (gr.  xx  to  oj) ;  dust  with  iodoform  ;  close 
the  upper  portion  of  the  wound  and  insert  a  drainage-tube 
in  the  lower  angle ;  dress  the  wound  antiseptically ;  place 
a  small  pad  in  the  axilla ;  apply  the  second  roller  of 
Desault;  and  put  the  patient  in  bed  with  a  pillow  under 
the  affected  shoulder.  In  seven  days  the  hand-sling  is 
substituted  for  the  bandage,  and  with  the  elbow  hanging 
free  the  patient  is  permitted  to  get  up  and  is  advised  to 
move  his  arm  frequently.  Drainage  is  maintained  until 
the  wound  is  well  healed  from  the  bottom.  Great  limi- 
tation of  mov^ement  inevitably  follows  upon  a  shoulder-joint 
resection. 

Excision  by  the  deltoid  flap  is  performed  when  the  head 
of  the  bone  is  much  enlarged  (as  by  a  tumor)  or  when  the 
tissues  are  thick  and  indurated.  The  deltoid  flap  is  in 
the  shape  of  a  V  or  is  semilunar  (Fig.  140,  a).  Raising  this 
flap  exposes  the  head  of  the  bone  most  satisfactorily.     Bell 


490  MODERN  SURGERY. 

states  that  when  the  glenoid  cavity  is  chiefly  involved  the 
incision  should  be  posterior  (Fig.  140,  b). 

Senn's  Method. — Senn  has  recently  described^  an  incision 
which  does  not  damage  any  important  vessels,  muscles,  ten- 
dons, or  nerves,  and  which  is  followed  by  good  functional 
results.  A  semilunar  skin-flap  is  formed,  the  incision  run- 
ning from  the  coracoid  process  to  the  posterior  border  of  the 
axillary  space.  This  flap  is  turned  up,  exposing  the  upper 
half  of  the  deltoid  muscle.  The  acromion  is  sawn  off  and 
turned  down  with  the  attached  deltoid.  The  capsule  is  now 
freely  exposed  ;  it  is  opened,  and  either  arthrectomy  or  excis- 
ion is  performed,  according  to  conditions.  In  closing  the 
wound  it  is  not  necessary  to  bore  the  acromion  and  pass 
silver  wires  to  join  the  fragments ;  it  is  enough  to  suture  the 
periosteum  with  catgut. 

Excision  of  the  Elbo-w-joint. — This  operation  is  per- 
formed for  wounds,  faulty  ankylosis,  and  chronic  articular 
disease.  Excision  must  be  complete.  Endeavor  to  make 
a  subperiosteal  resection ;  this  maintains  the  shape  of  the 
articulation  and  gives  the  best  chance  for  a  movable  joint. 
The  instruments  used  are  the  same  as  those  for  the  shoulder,, 
plus  a  Butcher  saw. 

Opej^ation. — The  patient  is  "  supine,  but  inclining  to  the 
sound  side,  the  affected  arm  being  held  almost  vertical,  with 
the  forearm  flexed  and  nearly  horizontal"  (Barker).  The 
incision  is  made  on  the  posterior  surface  of  the  joint.  A 
single  posterior  incision  is  usually  employed  (Fig.  140,  d,  f). 
An  incision  is  made  a  little  internal  to  the  long  axis  of  the 
olecranon,  and  reaching  two  inches  above  and  two  inches 
below  the  tip  of  the  olecranon.  This  incision  goes  down  to 
the  bone,  and  throughout  the  entire  operation  the  surgeon 
must  guard  and  shield  the  ulnar  nerve.  The  periosteum 
and  soft  parts  are  well  separated ;  the  olecranon  is  sawn  off  ;^ 
forced  flexion  exposes  the  joint-cavity  freely,  and  enables 
the  surgeon  to  lift  the  periosteum  and  soft  parts  from  the 
humerus  ;  the  humerus  is  sawn  through  at  the  beginning 
of  its  condyloid  processes ;  the  radius  and  ulna  are  cleared 
and  are  sawn  at  a  level  below  that  of  the  base  of  the  coro- 
noid  process  of  the  ulna.  Cut  and  spoon  away  diseased 
tissues,  the  wound  being  irrigated,  closed,  drained,  and  dressed. 
In  some  cases  an  H-shaped  incision  is  employed  (Fig.  140,  c),. 
but  the  cicatrix  of  a  transverse  cut  will  limit  flexion  of  the 
limb. 

After  excision  of  the  elbow  the  patient  is  put  to  bed  and 

1  Phila.  Med.  Jourti.,  Jan.  i,  1898. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    49 1 

the  arm  is  laid  upon  a  pillow,  the  elbow  being  placed  mid- 
way between  a  right  angle  and  complete  extension,  the  fore- 
arm being  placed  midway  between  pronation  and  supination. 
No  splint  is  used,  as  a  rule.  Esmarch  used  the  splint  shown 
in  Figure  141.  The  aim  in  treatment  is  to  obtain  a  freely 
movable  joint.  Passive  motion  is  begun  in  one  week,  when 
the  patient  gets  up.    The  hand  is  carried  for  a  time  in  a  sling. 


Fig.  141. — Esmarch's  splint  for  the  treatment  of  a  limb  after  excision  of  the  elbow-joint. 

Excision  of  the  Wrist-joint. — Bell  states  that,  whatever 
method  of  excision  is  chosen,  three  cardinal  rules  must  be 
borne  in  mind:  (i)  remove  all  the  diseased  bone,  including 
the  portions  of  the  radius,  ulna,  carpus,  and  metacarpus  which 
are  covered  with  cartilage ;  (2)  interfere  with  the  tendons  to 
the  least  possible  degree ;  and  (3)  begin  passive  motion  of 
the  fingers  very  early.  Many  surgeons  prefer  the  simple 
gouging  away  of  diseased  foci  and  the  scraping  of  sinuses 
instead  of  a  formal  resection  of  the  wrist,  amputation  being 
employed  in  severe  cases  or  when  scraping  fails  after  several 
trials.  Formal  excision  is  not  very  often  done,  and  the 
results  cannot  often  be  considered  as  very  favorable. 

Lister's  Open  Method  of  Excision. — The  instruments  re- 
quired in  this  operation  are  the  same  as  those  used  for  any 
resection.  Break  up  adhesions  as  completely  as  possible  by 
forcible  movements.  Apply  a  tourniquet  or  an  Esmarch  appa- 
ratus. The  patient  lies  upon  his  back,  the  arm  and  the  fore- 
arm being  brought,  from  stage  to  stage,  into  the  most  desirable 
positions.  Begin  an  incision  over  the  middle  of  the  dorsum 
of  the  radius,  on  a  level  with  the  styloid  process ;  carry  it 
downward  in  the  direction  of  the  inner  edge  of  the  articula- 
tion of  the  thumb  with  its  metacarpal  bone,  and  when  the 
knife  reaches  the  radial  side  of  the  second  metacarpal  bone 
alter  the  direction  of  the  incision  and  carry  it  downward  in 
the  long  axis  of  the  metacarpal  bone  to  about  its  middle 
(Fig.  138,  a).     This  is  known  as  the  radial  incision,  and  the 


492  MODERN  SURGERY. 

only  tendon  divided  is  that  of  the  extensor  carpi  radialis 
brevior  muscle.  The  tissues  upon  the  radial  aspect  of  the 
incision  are  dissected  up,  the  tendon  of  the  extensor  carpi 
radialis  longior  muscle  is  divided  at  its  point  of  insertion 
(Bell),  and  all  the  soft  structures  are  retracted  outward, 
exposing  the  trapezium,  which  is  cut  off  from  the  rest  of  the 
carpus,  but  which  is  left  in  place,  as  its  removal  at  this  stage 
endangers  the  radial  artery  (Barker).  By  extending  the 
hand  the  tendons  are  loosened  and  the  carpus  is  cleared  in 
the  direction  of  the  ulnar  border  of  the  hand. 

Another  incision  is  made,  starting  upon  the  inner  surface 
of  the  wrist,  two  inches  above  the  articular  surface  of  the 
ulna,  and  midway  between  the  ulna  and  the  flexor  carpi 
ulnaris  tendon.  This  incision,  which  is  known  as  the  nlnar 
incision,  is  carried  down  until  it  is  opposite  the  middle  of 
the  fifth  metacarpal  bone  in  the  palm  (Fig.  138,  b).  "The 
dorsal  lip  of  this  incision  is  raised  "  (Bell),  and  the  extensor 
carpi  ulnaris  tendon  is  divided  and  dissected  from  its  depres- 
sion, but  is  not  separated  from  the  integument.  The  extensor 
tendons  are  lifted ;  the  ligaments  upon  the  dorsum  and 
sides  of  the  wrist-joint  are  cut;  the  flexor  tendons  are  raised 
from  the  carpal  bones ;  the  pisiform  bone  is  cut  from  the 
carpus,  but  is  not  yet  removed ;  and  the  unciform  process  of 
the  unciform  bone  is  cut  with  forceps.  The  anterior  radio- 
carpal ligament  is  divided,  the  carpometacarpal  articulations 
are  cut  through,  and  the  carpus  is  pulled  out  with  bone- 
forceps.  The  ends  of  the  radius  and  ulna  are  forced  out  of 
the  ulnar  incision.  All  that  portion  of  the  ulna  which  is 
crusted  wdth  cartilage  is  to  be  removed,  the  saw-cut  is  to  be 
oblique,  and  the  base  of  the  styloid  process  is  to  be  left 
behind.  A  thin  section  is  to  be  sawn  from  the  radius,  and 
the  tendon-grooves  are  not  to  be  impinged  upon.  The  artic- 
ular surface  of  the  ulna  is  cut  away  with  pliers  (Bell).  If 
foci  of  disease  are  discovered  beyond  these  points,  they  are 
to  be  gouged  out.  The  ends  of  the  metacarpal  bones  are 
sawn  off,  and  their  articular  facets  are  cut  away  by  means 
of  pHers.  The  trapezium  is  dissected  out,  the  end  of  the 
first  metacarpal  bone  is  sawn  off  and  its  facet  is  cut  away 
with  pliers,  and  a  portion  of  the  pisiform  bone  is  removed 
(the  entire  bone  being  removed  if  it  be  diseased).  The 
wound  is  irrigated,  vessels  are  tied,  the  radial  incision  is 
closed,  the  ulnar  incision  is  partly  closed,  a  drainage-tube 
is  inserted  by  way  of  the  ulnar  incision,  the  wounds  are 
dressed  antiseptically,  and  the  Esmarch  apparatus  is  taken 
off.     The  forearm  and  hand  are  placed  upon  a  splint  which 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.    493 

immobilizes  the  wrist  and  leaves  the  fingers  semiflexed.  The 
splint  is  worn  for  man\-  months,  until  the  wrist-joint  is  immo- 
bile and  solid.     Esmarch  uses  the  splint  shown  in  Fig.  142. 


Fig.   142. — Esmarch's  interrupted  splint  applied. 


Passive  motion  of  the  fingers  is  begun  after  thirty-six 
hours. 

Excision  of  Metacarpal  Bones  and  of  Phalanges. — 
Excision  of  a  metacarpal  bone,  except  in  cases  of  necro- 
sis with  the  formation  of  large  quantities  of  new  bone, 
usually  leaves  a  useless  finger ;  hence  amputation  is  pre- 
ferred usually  to  excision.  This  rule  does  not  apply  to 
the  metacarpal  bone  of  the  thumb,  which  is  occasionally 
resected.  The  incision  for  this  operation  is  made  upon  the 
dorsum,  and  is  straight.  Excision  of  the  proximal  phalanx 
of  the  thumb  is  sometimes  performed.  Excision  for  disease 
is  rarely  performed  upon  the  finger-joints,  amputation  being 
preferred,  though  the  operation  is  sometimes  undertaken  for 
compound  dislocation.  In  the  metacarpophalangeal  joint 
of  the  thumb  excision,  if  it  can  be  performed,  is  preferred 
to  amputation.  The  incision  for  resection  of  this  joint  is 
placed  upon  the  radial  aspect. 

Excision  of  the  Hip-joint. — Some  surgeons  advocate  this 
operation  ;  others,  notably  Marsh,  are  emphatically  opposed 
to  it.  Excision  should  be  performed  in  the  early  stage  of 
tubercular  disease  if  less  radical  treatment  has  failed,  and  in 
this  stage  the  usual  position  of  the  limb  is  one  of  flexion, 
abduction,  and  eversion.  In  cases  of  long  duration,  espec- 
ially where  dislocation  exists,  excision  is  an  easy  and  a  com- 
paratively safe  operation  ;  in  recent  cases  it  is  difficult  and 
carries  with  it  decided  dangers,  but  the  peril  of  delay  may 
be  greater  than  the  peril  of  an  early  resection.  In  cases  of 
hip  disease  with  involvement  of  the  acetabulum  the  mor- 
tality is  50  per  cent,  whether  operation  is  or  is  not  at- 
tempted.    Excision    is  performed  especially  for  tubercular 


494 


MODERN  SURGERY. 


disease  and  for  gunshot-injuries.     The  instruments  required 
are  those  used  for  other  excisions. 

Operation  by  Antej'ior  Incision 
(Fig.  143)  (Parker's  Operation). 
— In  this  operation  the  patient  is 
supine,  with  the  thighs  extended 
as  thoroughly  as  circumstances 
permit.  The  surgeon  stands  to 
the  right  of  the  patient.  An 
incision  is  begun  half  an  inch 
below  and  half  an  inch  external 
to  the  anterior  superior  iliac 
spine,  and  it  is  carried  down- 
ward and  a  little  inward  for 
about  three  inches  (Fig.  143,  d). 
If  dislocation  exists,  the  incision 
must  not  be  so  long.  This  in- 
cision is  carried  at  once  deeply 
between  the  muscles,  and  the 
capsule  of  the  joint  is  opened. 
The  neck  of  the  bone  is  divided 
from  its  upper  surface  down- 
ward with  a  saw  or  an  osteotome, 
and  without  dislocating  the 
bone  through  the  wound  by  forcible  extension  and  eversion, 
the  head  of  the  bone  is  removed.  All  tubercular  foci  must 
be  scraped  away,  and  the  flushing  gouge  is  used  upon  tuber- 
cular areas  of  the  acetabulum.  All  sinuses  should  be  thor- 
oughly scraped.  Bleeding  is  arrested,  the  wound  is  irrigated 
with  corrosive-sublimate  solution,  mopped  out  with  chlorid- 
of-zinc  solution,  and  dusted  with  iodoform.  A  drainage-tube 
is  inserted  at  the  lower  angle  of  the  incision,  and  the  upper 
portion  of  the  cut  is  closed.  The  wound  is  dressed  antisep- 
tically.  Extension  is  made  with  the  extension  apparatus  until 
healing  has  obtained  a  good  headway,  when  a  double  Thomas's 
.splint  is  applied,  so  that  the  patient  can  be  taken  out  daily  in 
the  air  and  sunlight.  As  a  rule,  rigid  ankylosis  results  from 
resection  of  the  hip,  but  occasionally  a  joint  results  with  a 
small  range  of  movement. 

Operation  by  Lateral  Incision  (Langenbeck's  Operation). — 
In  this  operation  a  straight  incision  two  inches  long  is  made 
in  the  direction  of  the  axis  of  the  femur,  and  runs  downward 
from  the  apex  of  the  great  trochanter.  From  the  beginning 
of  this  incision  a  curved  incision  is  carried  toward  the  head 
of  the  bone,  the   convexity  of  the   curve  being  backward 


Fig.  143. — Excision  of  the  hip-joint : 
A,  gluteus  muscle ;  B,  tensor  vaginae 
femoris  muscle;  c,  sartorius  muscle; 
D,  anterior  incision. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    495 

(Fig.  137,  a).  Bell  advises  the  use  of  the  saw  after  bringing 
the  head  of  the  bone  into  the  wound  by  abduction  and  ever- 
sion  of  the  thigh.  Barker  applies  the  saw  with  the  bone  in 
situ,  and  strongly  opposes  wrenching  the  bone  out  of  the 
incision,  because  of  the  danger  of  peeling  off  the  periosteum, 
which  peeling,  if  it  takes  place,  favors  necrosis. 

Incision  of  Gross. — In  Gross's  operation  a  semilunar  flap 
is  made  with  the  convexity  backward  (Fig.  140,  e). 

Excision  of  the  Knee-joint. — In  this  operation  a  com- 
plete excision  should  be  performed,  and  the  patella  ought  to 
be  removed.  This  operation  is  performed  in  tubercular  dis- 
ease, in  some  compound  fractures  and  compound  disloca- 
tions, and  in  some  cases  of  angular  ankylosis,  but  it  is  rarely 
employed  for  gunshot-injuries,  amputation  being  advisable 
(Ashhurst).  The  instruments  required  are  the  same  as  those 
for  the  shoulder,  plus  Butcher's  saw. 

Operation  by  Anterior  Semilunar  Flap. — The  patient  lies 
upon  his  back,  and  the  joint,  if  not  ankylosed  in  extension, 
is  semiflexed.  The  surgeon  stands  to  the  right  side.  An 
incision  is  made,  at  once  opening  the  joint,  starting  from  one 
condyle  and  reaching  the  other  condyle  by  a  downward 
curve  which  passes  through  the  ligamentum  patellae  midway 
between  the  tuberosity  of  the  tibia  and  the  inferior  margin 
of  the  patella  (Fig.  139,  b).  The  flap  is  dissected  up,  the 
knee  is  thrown  into  forced  flexion,  the  lateral  ligaments  and 
crucial  ligaments  are  cut,  and  the  end  of  the  femur  is  well 
cleared.  The  blade  of  Butcher's  saw  is  passed  beneath  the 
bone,  which  is  sawn  from  below  upward  (Ashhurst).  The 
end  of  the  tibia  is  cleared  and  a  portion  is  sawn  off.  If,  after 
sawing,  diseased  foci  are  discovered,  another  section  can  be 
sawn  off  or  the  foci  can  be  gouged  away.  Ashhurst,  who  has 
had  a  vast  experience  with  this  operation,  insists  that  in  sawing 
through  the  femur  the  natural  obliquity  of  the  bone  must  be 
borne  in  mind  and  the  section  must  be  made  in  "  a  line  parallel 
to  that  of  the  free  surface  of  the  condyles."  If  the  section  is 
made  transverse  to  the  axis  of  the  femur,  "  the  limb,  after  ad- 
justment, will  be  found  to  be  markedly  bowed  outward."  The 
same  surgeon  says  that  the  epiphyseal  line  is  somewhat  higher 
on  the  front  than  it  is  on  the  back  of  the  femur,  and  in  con- 
sequence the  following  rule  is  formulated  for  section  of  the 
condyles :  the  section  of  the  condyles  should  be  "  in  a  plane 
which,  as  regards  the  axis  of  the  femur,  is  oblique  from  be- 
hind forward,  from  below  upward,  and  from  within  outward." 
Ashhurst  advocates  section  of  the  tibia  "  in  a  plane  trans- 
verse to  the  long  axis  of  the  bone,  w^ith  a  slight  anteroposte- 


496 


MODERN  SURGERY. 


rior  obliquity,  so  as  to  correspond  with  that  of  the  section  of 
the  cond}-les,"  and  further  says  also  that  the  patella  must  be 
removed,  whether  it  is  diseased  or  not,  and  he  quotes  Peniere's 
observations  to  the  effect  that  excision  of  the  patella  dimin- 
ishes the  risk  of  death  one-third,  and  its  retention  doubles  the 
probability  of  an  amputation  becoming  necessary  in  the  future. 
After  removing  the  patella  the  diseased  synovial  membrane 
is  clipped  away  with  scissors  and  all  sinuses  and  diseased 
territories  are  well  curetted.  The  posterior  ligament  of  the 
joint  is  not  removed  unless  it  is  diseased ;  its  retention  pre- 
vents displacement  and  guards  the  popliteal  space.  In  chil- 
dren the  fragments  should  be  wired  together ;  in  adults  this 
need  not  be  done.  After  hemostasia  irrigate,  dust  with  iodo- 
form, insert  a  drainage-tube,  suture,  dress  antiseptically,  and 
adjust  the  limb  upon  Price's  splint  or  Ashhurst's  bracketed 
wire  splint.  In  some  cases  tenotomy  is  required  to  permit 
extension.  Instead  of  the  bracketed  splint,  a  long  fracture-box 
may  be  used.  If  the  femur  tends  to  project  anteriorly,  use  an 
anterior  splint.  If  there  be  a  tendency  to  outward  bowing, 
adopt  Ashhurst's  expedient  of  carrying  a  strip  of  adhesive 
plaster  around  the  outside  of  the  limb  and  fastening  it  to  the 
inner  side  of  the  splint.  The  splint  is  kept  on  until  bony 
union  is  complete,  as  in  this  operation  a  movable  joint  is 
never  sought.  Many  surgeons  use  a  plaster-of-Paris  splint, 
which  is  employed  until  the  parts  have  become  firm  and  solid 
(Fig.  144). 


Fig.  144. — Watson's  plaster-of-Paris  swing-splint. 

Excision  of  the  Ankle-joint. — This  operation  is  per- 
formed chiefly  in  gunshot-wounds,  in  compound  dislocations, 
and  in  early  cases  of  chronic  joint-disease.  Complete  resec- 
tion is  employed  for  chronic  joint-disease.  Excision  of  the 
ankle  is  a  rare  operation.  The  instruments  used  are  the 
same  as  those  employed  for  any  resection. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    497 

Operation  (Hancock's  Method). — In  this  operation  the  pa- 
tient lies  upon  his  back,  the  foot  rests  upon  its  inner  side, 
and  the  surgeon  stands  to  the  outer  side  of  the  damaged  limb. 
Begin  an  incision  just  behind  and  two  inches  above  the  ex- 
ternal malleolus,  and  carry  it  across  the  front  of  the  joint  to  a 
corresponding  point  above  and  behind  the  internal  malleolus 
(Fig.  137,  b)  ;  this  incision  goes  only  through  the  skin,  and 
the  flap  thus  marked  out  is  reflected.  "  Cut  down  upon  the 
external  malleolus,  carrying  the  knife  close  to  the  edge  of  the 
bone  both  behind  and  below  the  process,  dislodge  the  peronei 
tendons,  and  divide  the  external  lateral  ligaments  "  (Joseph 
Bell).  Cut  the  fibula  one  inch  above  the  malleolus  by  means 
of  pliers;  divide  the  tibiofibular  ligament;  turn  the  foot  upon 
its  outer  side ;  dissect  from  their  habitat  back  of  the  inner 
malleolus  the  tendons  of  the  posterior  tibial  and  the  com- 
mon flexor  of  the  toes ;  carry  the  knife  around  the  inner 
malleolus,  close  to  the  bony  edge ;  separate  the  internal  lat- 
eral ligament,  and  dislocate  the  lower  end  of  the  tibia  through 
the  wound  by  turning  the  sole  of  the  foot  downward  ;  saw  off 
the  lower  end  of  the  tibia  and  the  articular  process  of  the 
astragalus,  sawing  away  from  the  tendo  Achillis,  and  remove 
the  fragments  with  bone-forceps.  Cut  away  diseased  syno- 
vial membrane,  and  curet  all  sinuses  and  tubercular  areas. 
Arrest  bleeding,  irrigate,  and  drain.  Sew  up  the  wound, 
insert  a  tube  at  the  outer  angle,  and  cause  it  to  emerge  at  the 
inner  angle.  Apply  antiseptic  dressings,  and  put  up  the  foot 
in  fixed  dressing  or  in  splints  at  a  right  angle  to  the  leg  (Fig. 
145).     In  Langenbeck's  operation  the  excision  is  subperios- 


145— Volkmann's  dorsal  splint  for  excision  of  the  ankle. 


teal.     If,  in  an  excision  of  the  ankle-joint,  the  astragalus  is 
found  extensively  diseased,  remove  the  entire  bone. 

Excision  of  the  Os  Calcis. — In  caries  limited  to  the  os 

32 


498  MODERN  SURGERY. 

calcis  most  surgeons  prefer  to  gouge  away  the  dead  bone, 
leaving  the  periosteum  and,  if  possible,  a  shell  of  healthy- 
bone,  and  draining  thoroughly.  Others  advocate  excision 
in  some  cases.  Extensive  disease  Hmited  purely  to  the  os 
calcis  is  rare,  and  most  surgeons  advise  gouging  for  limited 
caries,  and  Syme's  amputation  in  the  event  of  the  disease  ex- 
tending beyond  the  periosteum  or  reaching  adjacent  bones. 

Operation  by  Subperiosteal  Method. — In  this  operation  the 
position  assumed  by  the  patient  is  supine  with  the  leg 
extended  and  the  foot  resting  on  its  inner  side.  The 
incision,  which  cuts  the  tendo  Achillis  and  reaches  the 
bone  at  once,  is  begun  at  the  upper  border  of  the  os  calcis 
and  the  inner  margin  of  the  tendo  Achillis,  and  is  taken 
outward  and  horizontally  forward  to  a  point  in  front  of*  the 
calcaneocuboid  articulation.  A  vertical  incision  is  begun 
near  the  forward  termination  of  the  initial  incision,  is  carried 
across  the  outer  edge  and  plantar  surface  of  the  foot,  and 
terminates  at  the  external  margin  of  the  inner  surface  of  the 
OS  calcis.  Some  surgeons  carry  the  vertical  incision  a  little 
upward,  toward  the  dorsum  (Fig.  140,  f).  The  periosteum 
is  entirely  stripped  with  an  elevator,  the  os  calcis  is  removed, 
the  cavity  is  packed  with  iodoform  gauze,  the  wound  is 
stitched,  a  drain  is  inserted  posteriorly,  and  the  foot  is 
dressed  antiseptically  and  put  up  in  plaster  at  a  right  angle 
to  the  leg,  trap-doors  being  cut  for  drainage. 

Excision  of  the  astragalus  is  a  rare  operation. 

Operation  by  the  Subperiosteal  Plan. — Barker  advises  an 
incision  going  at  once  to  the  bone,  from  the  "  tip  of  the  ex- 
ternal malleolus  forward  and  a  little  inward,  curving  toward 
the  dorsum  of  the  foot."  The  foot  is  extended  and  turned 
inward,  the  periosteum  is  lifted,  the  bone  is  removed,  and 
the  wound  is  treated  and  the  foot  is  dressed  as  is  done  in 
excision  of  the  os  calcis. 

Excision  of  the  Metatarsophalangeal  Articulation  of 
the  G-reat  Toe. — In  this  operation  make  a  lateral  incision 
and  cut  off  or  saw  off  the  proximal  end  of  the  first  phalanx 
and  the  distal  third  of  the  first  metatarsal  bone. 

Excision  of  the  Metatarsal  Bone  of  the  Great  Toe 
(Butcher's  Method). — In  this  operation  a  lateral  straight 
incision  is  made,  the  periosteum  is  elevated,  and  the  shaft  is 
sawn  from  each  extremity  and  removed. 

Excision  of  the  clavicle  may  be  required  in  dislocation, 
in  caries,  in  necrosis,  for  gunshot-wounds,  in  tumor  of  this 
bone,  as  a  preliminary  to  ligation  of  the  artery  and  vein  in 
certain  cases  of  amputation  at  the  shoulder-joint,  or  in  cases 


DISEASES  AND   INJURIES   OF  BOA^ES  AND  JOINTS.    499 

of  removal  of  the  entire  upper  extremity.  In  excision  of 
the  clavicle  the  position  of  the  patient  is  the  same  as  that 
for  ligation  of  the  third  part  of  the  subclavian  artery  (page 
288).  An  incision  is  made  down  to  the  bone,  from  the 
sternoclavicular  joint  to  the  acromioclavicular  articulation. 
If  the  case  is  suitable,  the  periosteum  is  stripped  and  the 
bone  is  sawn  and  removed ;  if  not,  the  bone  is  sawn  and 
each  half  is  separately  disarticulated.  The  wound  is  sutured 
and  dressed,  and  the  limb  is  put  up  in  a  Velpeau  bandage. 

Excision  of  the  Scapula, — Complete  excision  of  the  scap- 
ula is  most  usually  performed  for  tumors.  Partial  excision 
requires  no  detailed  description.  In  excision  of  the  scap- 
ula the  patient  lies  upon  his  sound  side.  Treves  suggests 
the  following  incisions :  one  outside  the  vertebral  border 
of  the  scapula,  from  its  superior  to  its  inferior  angle ; 
another  from  over  the  acromioclavicular  joint,  along  the 
acromion  process  and  spine  of  the  scapula,  to  meet  the 
first  incision,  Syme  used  an  incision  carried  transversely 
inward  from  the  acromion  process  to  the  vertebral  border 
of  the  scapula,  and  another  cut  directly  downward  from 
the  center  of  the  first  incision  (Fig.  140,  g).  In  the 
method  of  Treves  ^  the  upper  flap  is  reflected  and  the 
trapezius  muscle  is  divided ;  the  lower  flap  is  reflected  and 
the  deltoid  muscle  is  divided.  The  patient's  hand  is  placed 
on  the  sound  shoulder ;  the  muscles  of  the  vertebral  border 
are  divided,  the  posterior  scapular  artery  is  tied,  and  while 
the  vertebral  border  of  the  scapula  is  pulled  toward  the 
surgeon  the  serratus  magnus  muscle  is  cut,  the  upper  border 
of  the  shoulder-blade  is  cleared,  and  the  suprascapular  artery 
is  tied.  The  hand  is  now  brought  down  to  the  side ;  the 
acromioclavicular  joint  is  disarticulated ;  the  conoid  and 
trapezoid  ligaments  are  divided ;  the  muscles  of  the  coracoid 
process  are  cut ;  the  capsule  is  incised,  with  the  supraspinatus 
and  infraspinatus,  the  subscapularis  muscles,  and  the  scapular 
origins  of  the  biceps  and  triceps  ;  and  finally  the  teres  major 
and  minor  muscles  are  divided,  the  subscapular  artery  is  tied, 
and  the  bone  is  removed.  The  wound  is  stitched,  a  drain  is 
introduced,  and  antiseptic  dressings  are  applied.  The  patient 
lies  upon  his  back  until  healing  is  well  under  way,  when  the 
arm  is  placed  in  a  sling.  The  drainage-tube  may  be  removed 
in  twenty-four  hours. 

Excision  of  a  Rib. — In  caries  the  gouge  and  rongeur  may 
remove  the  disease.  In  other  cases  excision  is  performed. 
In  this  operation  the  patient  lies  upon  his  sound  side.     The 

^  Treves's  Manual  of  Operative  Surgery. 


500    .  MODERN  SURGERY. 

surgeon  faces  the  patient.  Make  an  incision  down  to  the 
bone,  in  the  long  axis  of  the  rib.  The  periosteum,  if  not  dis- 
eased, is  hfted  from  the  bone,  and  the  intercostal  artery  is 
thus  saved  from  being  cut.  After  sawing  the  bone  beyond 
the  limits  of  disease,  remove  it.  During  the  sawing  a  metal 
retractor  is  held  beneath  the  rib,  between  the  rib  and  the 
periosteum.  If  the  periosteum  is  diseased,  remove  it  after 
tying  the  intercostal  artery.  Curet  sinuses.  Pack  with 
iodoform  gauze  for  some  days.  Sew  up  the  wound  except  at 
one  end.  Dress  antiseptically  and  apply  a  binder.  If  a  rib 
is  resected  in  order  to  drain  the  pleural  cavity,  remove  it  by 
the  subperiosteal  section,  ligate  the  artery  after  a  portion  of 
the  rib"  has  been  removed,  cut  away  the  periosteum  to  pre- 
vent re-formation  of  bone,  and  open  the  pleura.  (See  Opera- 
tions upon  the  Chest  and  Estlander's  Operation.) 

Complete  Excision  of  One-half  of  the  Upper  Ja'w. — 
The  whole  upper  jaw  has  been  removed,  but  in  what  fol- 
lows only  resection  of  one-half  the  jaw  will  be  described. 
This  operation  is  performed  for  malignant  tumors  of  the 
superior  maxillary  bone  or  its  antrum.  Up  to  1826,  at  which 
time  Lizars  of  Edinburgh  suggested  the  operation,  tumors 
of  the  antrum  were  treated  by  scraping  them  away  with  a 
sharp  spoon.  Gensoul  of  Lyons  in  1827  performed  the  first 
operation  for  resection  of  the  upper  jaw.  This  operation  is 
not  justifiable,  except  as  a  palliative  measure,  if  the  orbit  is 
invaded,  if  the  skin  and  subcutaneous  tissues  are  infiltrated, 
or  if  the  disease  extends  beyond  the  superior  maxillary  and 
palate  bones.  The  instruments  required  are  a  mouth-gag ; 
scalpels ;  strong  scissors ;  dissecting,  toothed,  and  hemo- 
static forceps ;  bone-cutting  forceps ;  lion-jaw  and  seques- 
trum-forceps ;  tooth-extracting  forceps  ;  a  volsella ;  a  narrow- 
bladed  saw ;  a  chisel  and  mallet ;  a  periosteum-elevator ;  a 
spatula  or  metal  retractor ;  Paquelin's  cautery ;  sponges 
which  are  tied  to  sticks ;  needles,  curved  and  straight ;  silk 
and  catgut  ligatures  ;  silkworm-sutures  ;  large  curved  needles; 
and  Horsley's  antiseptic  bone-wax. 

Operation  by  Median  Incision. — The  patient,  whose  face  has 
been  shaved,  is  placed  in  the  Trendelenburg  position,  thus 
avoiding  the  possible  need  of  instant  tracheotomy.  The 
surgeon  stands  to  the  right  side  of,  and  faces,  the  pa- 
tient. The  incisor  tooth  on  the  diseased  side  is  pulled 
out.  The  incision  (Fig.  146,  line  A  b)  is  begun  half  an  inch 
below  the  inner  canthus  of  the  eye,  and  is  carried  along  the 
side  of  the  nose,  around  the  ala  of  the  nose,  by  the  margin 
of  the  nostril,  and  through  the  middle  of  the  lip.     While 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.    50I 


Fig.  146. ^a  b.  excision  of  the  upper 
jaw  ;  c  D  E,  excision  of  the  lower  jaw. 


the  lip  is  being  incised  the  assistant  arrests  hemorrhage 
by  grasping  the  corners  of  the  mouth,  and  after  the  Hp  is 
divided  the  coronary  arteries  are 
at  once  Hgated.  Some  operators 
approach  the  mucous  membrane 
cautiously  and  ligate  the  vessels 
before  opening  the  cavity  of  the 
mouth.  The  upper  portion  of  the 
wound  having  been  compressed 
by  another  assistant  during  these 
manipulations,  pressure  is  now 
removed  and  bleeding  points  are 
ligated.  Another  incision  is  now 
carried  outward  from  the  begin- 
ning of  the  first  incision,  along  the 
orbital  margin  to  well  over  the 
malar  bone.  The  flap  is  lifted 
from  the  periosteum,  and  the 
bleeding  from  the  infraorbital  artery  and  the  small  vessels  is 
restrained  by  pressure.  The  nasal  cartilage  is  separated  from 
the  bone,  and  the  nasal  process  of  the  superior  maxillary  is 
sawn  (line  a  b,  Fig.  147).  The  orbital  periosteum  is  lifted 
up,  and  the  orbital  plate  is  cut  with 
forceps  from  the  saw-cut  in  the  supe- 
rior maxillary  bone  to  the  spheno- 
maxillary fissure  (line  b  c,  Fig.  147). 
The  malar  bone  is  sawn  or  is  bitten 
through  about  its  center,  the  cut 
running  into  the  sphenomaxillary 
fissure  and  taking  a  downward  and 
outward  direction  (line  CD,  Fig.  147). 
The  soft  parts  covering  the  hard 
palate  are  incised  in  the  median  line, 
a  corresponding  incision  is  made 
along  the  floor  of  the  nose  near  the 
septum,  and  the  soft  palate  is  sepa- 
rated from  the  hard  palate  by  a  trans- 
verse cut.  The  saw  is  introduced 
through  the  nose,  and  the  palate  is 
sawn  (line  e.  Fig.  147).  The  upper 
jaw-bone  is  grasped  with  Fergusson's 
lion-jaw  forceps  and  removed,  the 
removal  being  aided  by  the  use  of  the  scissors  and  bone- 
cutters  ;  the  latter  are  used  to  separate  the  upper  jaw  from 
the  pterygoid  process  (Treves).     Every  vessel  that  can  be 


Fig.  147. — I.  Excision  of  the 
upper  jaw  :  A  B,  section  of  the 
nasal  process  ;  B  c,  section  of  the 
orbital  plate ;  D,  section  of  the 
malar  bone  and  orbital  plate  ;  e, 
section  of  the  alveolus,  and  hard 
palate.  2.  Excision  of  the  lower 
jaw;  G,  section  of  the  inferior 
maxillary;  H,  section  of  the 
ramus  in  partial  resection. 


502  MODERN  SURGERY. 

seen  is  tied,  and  severe  bleeding  from  bone  is  arrested  by 
antiseptic  wax.  Oozing  is  controlled  by  hot  water  and 
pressure  or  by  Paquelin's  cautery.  Examine  carefully  to 
see  if  all  the  diseased  area  is  removed ;  if  it  is  not,  use 
the  gouge,  scissors,  chisel,  and  saw  until  healthy  tissue  is 
reached.  The  wound  is  packed  with  iodoform  gauze,  and 
the  end  of  the  strip  is  so  placed  as  to  be  accessible  through 
the  mouth.  The  wound  is  sutured  (the  mucous  membrane 
of  the  lip  must  be  stitched,  as  well  as  the  skin)  and  is  dressed 
antiseptically  (the  eye  being  protected  by  aseptic  gauze),  and 
a  crossed  bandage  of  the  angle  of  the  jaw  is  applied. 

Excision  of  One-half  of  the  Lo^wer  Ja^w. — In  some  rare 
instances  the  entire  inferior  maxillary  bone  is  removed.  The 
lesions  necessitating  removal  of  the  lower  jaw  are  of  the 
same  nature  as  cause  us  to  remove  the  upper  jaw.  The 
instruments  required  for  removal  of  the  lower  jaw  are  those 
used  for  excision  of  the  upper  jaw,  plus  a  metacarpal  saw 
(having  a  movable  back). 

In  this  operation  the  patient  is  placed  in  the  same  posi- 
tion as  for  excision  of  the  upper  jaw,  the  chin  having 
been  previously  shaved.  A  vertical  cut  is  made  through 
the  chin-tissue,  starting  below  the  margin  of  the  lip  and 
reaching  to  below  the  border  of  the  jaw  (c  d.  Fig.  146). 
From  the  point  d  an  incision  is  carried  outward  below 
the  border  of  the  jaw  and  then  back  of  the  ramus,  as 
shown  in  the  line  d  e  (Fig.  146).  Treves's  advice  is  to 
carry  this  incision  down  to  the  bone,  except  at  the  line 
of  the  facial  artery,  at  which  point  it  must  go  through 
the  skin  only.  The  facial  artery  is  now  to  be  sought 
for,  tied  in  two  places,  and  divided.  The  periosteum  is  lifted 
from  the  external  surface  of  the  bone,  from  the  symphysis 
outward.  Hemorrhage  is  arrested.  The  buccal  mucous 
membrane  is  cut  from  the  alveolus.  A  lateral  incisor  tooth 
is  pulled,  and  the  bone  is  sawn  in  the  line  g  (Fig.  147). 
The  bone  is  grasped  in  a  lion-jaw  forceps  and  is  drawn 
outward.  The  mylohyoid  insertion  is  cut ;  the  internal 
pterygoid  muscle  is  cut  or  the  periosteum  at  this  spot  is 
lifted ;  the  inferior  dental  artery  is  cut  and  tied ;  the  jaw  is 
pulled  down ;  the  insertion  of  the  temporal  muscle  upon  the 
coronoid  process  is  cut  away ;  and  the  external  pterygoid 
muscle  is  divided.  The  capsule  of  the  joint  is  opened,  and 
the  bone  is  separated  from  the  ligaments  which  still  hold  it 
in  place.  Bleeding  is  arrested,  the  wound  is  sutured,  a  tube 
is  introduced  in  the  posterior  portion  of  the  wound  and 
retained  for  twenty-four  hours,  and  antiseptic  dressings  and 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.    503 

a  Gibson  or  a  Barton  bandage  are  applied.  Partial  excisions 
of  the  alveolus  may  be  performed  through  the  mouth  by 
means  of  chisels  and  rongeur  forceps,  and  Wyeth  has  re- 
moved half  of  the  jaw  by  this  method ;  but  if  any  consider- 
able part  of  the  body  of  the  jaw  is  to  be  removed,  it  is  usually 
best  to  make  an  incision  below  the  jaw. 

Operation  for  Congenital  Dislocation  of  Hip. — Hoffa's 
Operation. — The  instruments  used  are  the  same  as  for  a 
resection.  Make  the  external  incision  of  Langenbeck  to 
open  the  joint  (page  494).  The  capsule  is  incised  at  its  inser- 
tion into  the  neck,  and  the  periosteum  and  muscles  are  lifted 
from  the  great  trochanter.  Hoffa  claims  that  in  children 
less  than  five  years  of  age  the  head  can  be  readily  replaced 
into  the  acetabulum  by  flexing  the  thigh  and  making  direct 
pressure  upon  the  head  of  the  bone.  After  replacing  the 
head  it  is  held  in  place  while  an  assistant  extends  the  leg 
in  order  to  stretch  the  muscles.  In  children  over  five  years 
of  age  cut  the  muscles  which  spring  from  the  ischial  tube- 
rosity and  also  the  adductors  with  a  tenotome  ;  cut  the  fascia 
lata  and  muscles  which  arise  from  the  anterior  superior  iliac 
spine  by  incision;  open  the  joint  and  hberate  the  head; 
remove  the  ligamentum  teres ;  scrape  out  the  acetabulum, 
removing  "  cartilage,  fat,  and  considerable  spongy  tissue " 
(Tubby) ;  and  replace  the  head  in  the  acetabulum.  The  limb  is 
maintained  in  inversion,  abduction,  and  extension  for  several 
weeks,  when  it  is  straightened.  Massage  and  passive  motion 
are  begun  in  the  fifth  week.  The  patient  now  gets  about, 
wearing  an  apparatus  for  many  weeks.  This  apparatus  per- 
mits the  head  of  the  bone  to  move  in  the  socket,  but  pre- 
vents redislocation. 

Lorcnz's  Operation. — This  is  a  modification  of  Hofifa's. 
The  muscles  inserted  into  the  greater  trochanter  and  the 
lesser  trochanter  are  not  cut ;  the  sartorius,  the  hamstrings, 
and  the  external  portion  of  the  fascia  lata  are  cut  (Tubby). 

The  incision  of  Lorenz  is  longitudinally  from  the  anterior 
superior  spine.  Another  incision  is  carried  inward  from  this 
at  the  level  of  the  lesser  trochanter.  The  capsule  is  opened 
by  a  crucial  cut ;  the  acetabulum  is  enlarged ;  the  head  of 
the  bone,  if  it  remains,  is  inserted  into  the  acetabulum ;  if 
there  is  no  true  head,  a  new  one  is  formed  and  inserted  into 
the  cavity.  The  Hmb  is  immobilized  in  a  position  of  mod- 
erate abduction.  Massage  and  passive  motion  are  begun  in 
the  fifth  week,  and  are  continued  for  months.^ 

^  I  have  drawn  from  the  very  lucid  description  of  these  operations  in  A.  H. 
Tubby's  treatise  upon  "  Deformities." 


504  MODERN  SURGERY. 

XX.  DISEASES    AND    INJURIES   OF    MUSCLES,    TEN= 
DONS,   AND   BURS>E. 

Myalgia,  or  muscular  rheumatism,  is  a  painful  dis- 
order of  the  voluntary  muscles  and  of  the  fibrous  and  peri- 
osteal areas  where  they  are  attached.  The  term  "  muscular 
rheumatism  "  is  not  strictly  correct.  It  is  possible  that  in 
some  cases  the  muscular  structure  is  inflamed,  but  it  is  cer- 
tain that  in  many  cases  the  pain  is  distinctly  neuralgic. 
Muscular  rheumatism  may  be  due  to  cold  and  wet,  to  over- 
exertion and  strain,  to  acute  infectious  disorders,  to  syphilis, 
to  chronic  intoxications  (lead,  mercury,  and  alcohol),  and  to 
disturbances  of  the  circulation.  Gouty  and  rheumatic  per- 
sons are  especially  predisposed,  men  being  more  liable  to 
the  disease  than  women.  The  disease  is  usually  acute,  but 
it  may  be  chronic. 

Symptoms. — Muscular  rheumatism  is  apt  to  come  on 
suddenly.  The  pain,  which  may  be  very  acute  and  lanci- 
nating or  may  be  dull  and  aching,  is  in  some  cases  con- 
stantly present;  in  other  cases  it  is  awakened  only  by 
muscular  contraction.  The  pain  is  frequently  reheved  by 
pressure,  though  there  is  often  some  soreness.  The  skin 
above  the  muscle  is  sometimes  tender  to  light  pressure. 
The  disease  usually  lasts  for  a  few  days,  but  it  tends  to  recur. 
There  is  little,  if  any,  fever. 

Lumbago  is  myalgia  of  the  muscles  of  the  loins.  Rheu- 
matic torticollis  is  myalgia  of  the  muscles  of  the  neck. 
Usually  one  side  of  the  neck  is  attacked.  The  chin  is  turned 
from  the  affected  side  and  the  neck  is  stiff.  Pleurodynia 
is  myalgia  of  the  intercostal  muscles.  The  pain  is  very 
severe,  is  aggravated  by  deep  respiration,  by  coughing,  and 
by  yawning,  there  may  be  tenderness,  and  the  patient  tries 
to  limit  chest-movement.  In  intercostal  neuralgia  the  pain 
is  limited,  is  not  constant,  but  occurs  in  distinct  paroxysms, 
and  is  linked  with  the  presence  of  the  tender  spots  of  Val- 
leix.  Pleurodynia  lacks  the  physical  signs  of  pleurisy. 
Myalgia  must  not  be  confused  with  the  pains  of  locomotor 
ataxia.  Cephalodynia  is  myalgia  of  the  muscles  of  the  scalp. 
The  muscles  of  the  shoulder,  upper  dorsal  region,  abdomen, 
and  extremities  may  also  be  attacked  by  myalgia. 

Treatment. — Remove  any  obvious  cause.  Treat  any  ex- 
isting diathesis,  such  as  gout  or  rheumatism.  Rest  is  of  the 
first  importance.  For  lumbago,  put  the  person  to  bed.  For 
pleurodynia,  strap  the  side  of  the  chest.  A  hypodermatic 
injection  of  morphin  and  atropin  into  the  affected  muscles  at 


DISEASES  AND   INJURIES   OF  MUSCLES,   ETC.         505 

once  allays  the  pain,  and  a  deep  injection  of  water  is  often 
curative.  The  introduction  of  four  or  five  aseptic  needles 
into  the  muscles,  and  their  retention  for  a  few  minutes,  some- 
times act  most  favorably.  Ironing  the  skin  above  the  pain- 
ful muscles  is  a  useful  domestic  remedy.  Vigorous  rubbing 
of  the  area  with  a  piece  of  ice  allays  the  pain.  Hot  poultices 
do  good.  If  the  pain  is  widely  diffused,  alters  its  seat,  or  is 
very  obstinate,  order  hot  baths  or  Turkish  baths  and  admin- 
ister diuretics.  In  chronic  cases  employ  blisters  or  counter- 
irritation  by  the  cautery,  give  iodid  of  potassium  and  nux 
vomica,  and  have  the  patient  take  a  Turkish  bath  every 
week.  The  constant  electric  current  finds  advocates.  In 
an  ordinary  severe  case  order  a  hot  bath,  put  the  patient  to 
bed  with  a  hot-water  bag  over  the  part,  and  administer  10 
grains  of  Dover's  powder ;  the  next  morning  order  to  be 
taken  four  times  daily  a  capsule  containing  5  grains  of 
salol  and  3  grains  of  phenacetin,  until  the  pain  disappears. 
Citrate  of  potassium,  citrate  of  lithium,  chlorid  of  ammonium, 
or  the  salicylate  of  colchicin  may  be  ordered. 

Infective  myositis  is  a  widespread  inflammation  of  the 
voluntary  muscles,  due  to  an  unknown  infective  cause.  It  is 
a  disorder  accompanied  by  pain  and  stiffness,  by  cutaneous 
edema,  and  by  various  paresthesiae.  Myositis  resembles 
trichinosis,  and  is  distinguished  from  it  only  by  spearing  out 
a  bit  of  muscle  and  examining  it  microscopically.  Occasion- 
ally diffuse  suppuration  occurs.  Ordinary  myositis  arises 
from  injuries,  from  syphilis,  or  from  rheumatism,  and  it  pre- 
sents the  usual  inflammatory  symptoms.  Contraction  and 
adhesions  may  follow. 

Treatment. — Infective  myositis  is  treated  by  anodynes, 
stimulants,  nutritious  food,  hot  applications,  and  rest.  If 
pus  forms,  it  should  be  evacuated.  Rheumatic  myositis  calls 
for  the  administration  of  the  salicylates,  the  alkalies,  or  salol. 
Syphilitic  myositis  is  treated  with  mercury  and  iodid  of 
potassium.  The  remedies  employed  for  myalgia  are  used 
in  traumatic  myositis. 

Hypertrophy  of  the  muscles  may  arise  from  their  in- 
creased use.  In  pseudohypertrophic  paralysis  the  bulk  of 
the  muscle  is  greatly  augmented,  but  it  contains  less  muscle- 
structure  and  more  fat  or  connective  tissue. 

Atrophy  of  the  muscles  arises  from  want  of  use,  from 
injury,  from  continuous  pressure,  from  interference  with  the 
blood-supply,  from  disease  of  the  nerves  or  their  centers,  or 
from  lead-poisoning. 

Degeneration  of  Muscles. — The  muscles  may  undergo 


506  MODERN  SURGERY. 

granular  degeneration,  waxy  degeneration,  fatty  degenera- 
tion, and  calcareous    degeneration,  and   may  become   pig- 
mented. 
I/Ocal  Ossification  and  Myositis  Ossificans. — It  is 

not  unusual  for  a  small  portion  of  bone  to  form  in  the  peri- 
osteal insertion  of  a  muscle  which  is  subjected  to  frequent 
strain.  In  persons  who  ride  many  hours  a  day  there  not 
infrequently  develops  the  "rider's  bone,"  which  is  an  area  of 
ossification  in  the  adductor  muscles  of  the  thigh.  Myositis 
ossificans,  a  widespread  ossification  of  the  muscles,  is  a  rare 
disorder  the  cause  of  which  is  unknown,  and  which  if  not 
congenital  begins  at  least  in  early  life. 

IHiniors  of  the  Muscles. — Primary  tumors  of  the  mus- 
cles are  rare.  Among  those  which  may  occur  are  sarcoma, 
fibroma,  lipoma,  osteoma,  angioma,  myxoma,  and  enchon- 
droma.  Most  cases  of  supposed  primary  sarcoma  of  mus- 
cle are  in  reality  cases  of  syphiloma  (Esmarch). 

Syphilis  may  cause  inflammation.  Gummata  may  form, 
or  gummatous  infiltration  may  take  place. 

Trichinosis  or  trichiniasis  is  a  disease  due  to  the 
embryos  of  the  trichina  spiralis.  The  disease  originates 
from  eating  insufficiently  cooked  meat  which  contains  the 
trichinae.  These  nematodes  are  carried  into  the  intestine, 
there  to  develop  and  multiply.  In  from  seven  to  nine 
days  a  horde  of  embryos  develop  in  the  bowel,  and  leave 
the  aHmentary  canal  by  passing  through  the  peritoneum  or 
by  means  of  the  blood,  and  finally  reach  the  connective 
tissue  of  the  muscles.  From  the  connective  tissue  the  em- 
bryos migrate  into  the  primitive  muscle-fibers,  where  they 
dwell  and  enlarge.  Myositis  develops,  and  in  the  course 
of  five  or  six  weeks  the  parasites  become  encapsuled  and 
develop  no  further.  The  cyst-walls  may  calcify  and  the  worms 
may  become  calcified,  or  may  live  for  years.  Because  in- 
fected meat  is  eaten  the  disease  does  not  inevitably  develop, 
and  a  few  embryos  lodged  in  muscle  may  cause  no  symp- 
toms. 

Symptoms. — The  symptoms  of  trichinosis  often  appear  in 
a  day  or  two  after  eating  infected  meat.  The  symptoms  of 
acute  gastro-intestinal  catarrh  or  of  cholera  morbus  are  com- 
mon, but  in  some  cases  no  gastro-intestinal  manifestations 
usher  in  the  disease.  In  from  seven  to  fourteen  days  after  the 
infected  meat  is  eaten  the  migration  of  the  parasites  develops 
obvious  symptoms.  A  chill  may  be  noted ;  there  is  usually 
fever ;  muscular  pain,  tenderness,  swelling,  and  stiffness  are 
complained  of    This  condition  may  be  widespread.    Involve- 


DISEASES  AND   INJURIES   OF  MUSCLES,   ETC.         507 

ment  of  the  muscles  of  mastication  interferes  with  chewing; 
of  the  lary-nx,  with  audition  and  respiration  ;  of  the  inter- 
costals  and  diaphragm,  with  respiration.  Skin-edema  and 
itching  are  marked.  In  some  cases  dehrium  exists.  The 
writer  saw  in  the  Philadelphia  Hospital  one  fatal  case  which 
was  mistaken  for  erysipelas  because  of  the  high  fever,  the 
delirium,  and  the  edematous  redness  of  the  face  and  neck, 
D}-spnea  is  frequent.  Mild  cases  get  well  in  a  week  or  two ; 
severe  cases  may  last  many  weeks.  The  mortality  varies 
in  different  epidemics  from  i  to  30  per  cent.  (Osier).  The 
diagnosis  is  made  by  spearing  out  a  piece  of  muscle,  which 
is  then  examined  for  trichinae  under  a  microscope ;  or  the 
worm  may  be  detected  in  the  feces  by  means  of  a  pocket- 
lens. 

Treatment. — To  treat  trichinosis  employ  purgatives 
(senna  and  calomel)  early  in  the  case,  and  give  glycerin, 
and  also  santonin  or  filix  mas.  When  muscular  invasion 
has  taken  place,  sedatives,  hypnotics,  nourishing  diet,  and 
stimulants  are  indicated. 

Wounds  and  Contusions  of  the  Muscles. —  Wounds 
of  muscles  may  be  either  open  or  siibciitancoiis.  In  a  longi- 
tudinal wound  the  edges  lie  close  together,  and  hence  drain- 
age must  be  provided  for  by  the  surgeon.  In  a  transverse 
wound  the  edges  separate  widely,  and  catgut  stitches  must 
be  inserted.  Contusions  of  muscles,  like  contusions  of  other 
tissues,  \-Axy  in  extent  and  in  severity.  There  are  pain  (which 
is  increased  by  attempts  to  use  the  muscle),  loss  of  function, 
swelling  beneath  the  deep  fascia,  and  discoloration,  which 
may  appear  at  once  because  of  superficial  damage  from  the 
initial  injury,  or  which  may  appear  in  dependent  parts  after 
many  days  by  gravitation  of  the  blood  and  the  blood-stained 
serum.  As  a  result  of  contusion,  suppuration,  inflammation, 
or  atrophy  may  arise. 

Treatment. — The  indications  in  wounds  and  contusions 
of  muscles  are  to  obtain  rest  by  means  of  splints  and  to 
secure  relaxation.  Limitation  of  swelling  is  secured  by 
bandaging.  Inflammation  is  combated  first  by  cold  and  lead- 
water  and  laudanum  ;  later  by  iodin,  blue  ointment,  ichthyol, 
and  intermittent  heat.  To  prevent  loss  of  function  employ, 
as  soon  as  the  acute  symptoms  subside,  massage,  passive 
motion,  and  stimulating  liniments,  and,  later  in  the  case,  elec- 
tricity (galvanism  if  the  reactions  of  degeneration  exist, 
faradism  if  they  are  absent). 

Strains  and  Ruptures. — A  strain  is  a  stretching  of  a 
muscle  with  a  small  amount  of  rupture.     The  muscle  is 


508  MODERN  SURGERY. 

swollen,  tender,  stiff,  weak,  and  sore,  and  attempts  at  motion 
produce  sharp  pain.  Strains  are  common  in  the  deltoid,  the 
hamstring  muscles,  the  back,  the  calf,  the  biceps,  and  the 
great  pectoral.  Strain  of  the  psoas  muscle  causes  pain  on 
flexing  the  thigh,  and  is  associated  with  tenderness  in  the 
iliac  fossa.  Strain  of  the  right  psoas  may  be  mistaken  for 
appendicitis,  but  it  lacks  the  intense  local  tenderness,  the 
abdominal  rigidity,  and  the  constitutional  symptoms. 
"Lawn-tennis  arm  "  is  a  strain  of  the  pronator  radii  teres 
muscle,  "  Rider's  leg  "  is  a  strain  of  the  adductor  muscles 
of  the  thigh.  A  strain  may  be  the  only  injury,  or  may  be 
associated  with  some  other  condition  (fracture  of  bone,  dis- 
location, sprain,  contusion,  etc.). 

The  muscle  is  often  rigid,  is  tender,  and  pains  greatly  when 
an  attempt  is  made  to  use  it.  The  skin  over  it,  especially 
over  its  point  of  insertion,  is  usually  tender. 

A  strain  of  the  back  is  a  very  common  accident  which 
is  often  associated  with  sprains  of  the  vertebral  hga- 
ments.  There  is  great  pain  when  the  patient  voluntarily 
straightens  up.  If  the  vertebral  ligaments  are  not  sprained, 
the  patient  can  be  straightened  by  passive  motion  with- 
out pain.  The  skin  is  tender  in  certain  areas.  The  mus- 
cles are  often  rigid.  There  may  be  unilateral  rigidity.  In  a 
back  injury  make  a  careful  examination  to  be  sure  there  is 
no  damage  to  vertebrae  or  cord. 

Treatment. — Relaxation  by  suitable  position  ;  rest  by  the 
use  of  splints  or  by  putting  the  patient  to  bed ;  bandages  for 
compression  ;  hot  fomentations  or  hot  lead-water  and  lauda- 
num ;  ichthyol.  As  soon  as  acute  symptoms  subside  employ 
frictions  and  massage.  If  there  is  much  pain  after  a  strain, 
administer  Dover's  powder,  or  even  morphin. 

Rupture  of  a  muscle  is  announced  by  a  sudden  and  vio- 
lent pain  and  by  loss  of  function  arising  during  powerful  mus- 
cular contraction  or  strong  traction  on  a  muscle.  The  rupt- 
ure may  be  announced  by  a  clearly  audible  snap  (A.  Pearce 
Gould).  A  distinct  gap  is  felt  between  the  ends  ;  great  pain 
develops  on  movement ;  there  are  tenderness,  loss  of  power, 
and  swelling.  Strains  and  rupture  may  be  followed  by 
atrophy,  as  are  contusions.  Among  the  muscles  which 
occasionally  rupture  we  may  mention  the  quadriceps,  biceps, 
triceps,  deltoid,  etc. 

Treatment. — In  limited  rupture  treat  as  a  severe  strain. 
In  treating  extensive  rupture  of  an  important  muscle,  when 
the  ends  are  widely  separated,  incise  with  every  aseptic  care, 
unite  the  divided  ends  by  sutures  of  chromic  catgut,  and 


DISEASES  AND   INJURIES   OF  MUSCLES,   ETC.         509 

sew  up  the  skin  with  silkworm-gut.  Treat  the  part  in  any 
case  by  rest  and  relaxation,  and  combat  inflammation  by 
appropriate  means.  Passive  motion  and  massage  are  em- 
ployed as  soon  as  union  is  firm.  In  rupture  of  the  quad- 
riceps extensor  femoris  operation  should  be  undertaken,  be- 
cause mechanical  treatment  gives  frequently  a  bad  result  and 
confines  the  patient  to  bed  for  many  weeks. 

Hernia  of  Muscles. — When  a  tear  takes  place  in  a  mus- 
cular sheath  a  portion  of  the  muscle  protrudes.  The  treatment 
is  incision  and  the  stitching  of  the  fascia. 

Contractions  of  muscles  may  result  from  injury,  from 
joint-disease,  from  malposition  of  parts  (as  in  old  dislocation 
or  torticollis),  or  from  diseases  of  the  nervous  system.  The 
treatment  in  some  cases  is  sudden  extension,  in  other  cases 
gradual  extension,  tenotomy,  or  myotomy.  Macewen  recom- 
mends the  making  of  a  number  of  V-shaped  incisions  in  the 
muscle.  In  some  cases  of  spasmodic  contraction  nerve- 
stretching  is  of  value. 

Dislocation  of  Muscles  and  Tendons. — The  long 
head  of  the  biceps  is  oftenest  displaced.  The  flexor  carpi 
ulnaris,  the  peroneus  brevis,  the  peroneus  longus,  the  tibialis 
posticus,  the  sartorius,  the  plantaris,  the  quadriceps  extensor 
femoris,  and  the  extensors  back  of  the  wrist,  may  be  dislo- 
cated. What  is  known  as  dislocation  of  the  latissimus  dorsi, 
a  condition  in  which  that  muscle  no  longer  lies  upon  the 
angle  of  the  scapula,  is  not  a  dislocation,  but  a  paralysis. 
Most  of  these  accidents  are  associated  with  chronic  joint- 
disease  or  with  fracture,  but  displacement  may  exist  as  a 
solitary  injury.  Dislocation  of  the  long  head  of  the  biceps 
may  occur  tolerably  early  in  the  progress  of  rheumatoid 
arthritis  of  the  shoulder-joint,  and  the  displaced  tendon  may 
be  absorbed. 

Symptoms. — After  dislocations  of  a  tendon  the  muscle 
of  the  tendon  can  still  contract,  but  it  acts  at  a  disadvan- 
tage ;  thus  the  corresponding  joint  exhibits  partial  loss  of 
function.  The  displaced  tendon  can  be  felt,  and  a  hollow 
exists  where  it  normally  resides.- 

When  the  muscle  contracts  the  tendon  is  felt  to  slip  from 
its  groove.  When  the  tendon  of  the  biceps  is  dislocated  the 
head  of  the  bone  passes  forward  (so-called  subluxation  of 
the  humerus). 

Treatment. — In  tendon-dislocation  reduction  is  easy,  but 
the  displacement  is  apt  to  recur  because  of  laceration  of  the 
sheath.  The  treatment  usually  advised  is  to  reduce  the  ten- 
don by  relaxation  of  the  limb  and  manipulation  of  the  tendon. 


5IO  MODERN  SURGERY. 

Place  upon  a  splint,  so  that  the  muscle  belonging  to  the  ten- 
don is  relaxed,  and  apply  pressure  over  the  point  of  injury. 
This  treatment  usually  fails,  and  if  the  tendon  does  not  be- 
come anchored  firmly  in  four  weeks  we  should  operate.  In 
some  tendons  it  is  enough  to  incise,  freshen  the  edges  of  the 
torn  sheath,  and  sew  up  with  kangaroo-tendon  or  chromic 
catgut.  In  a  tendon  lying  in  a  long  groove,  make  a  halter 
for  the  tendon  by  incising  the  periosteum  and  suturing  it 
over  the  tendon.^  Passive  movements  are  begun  at  the  end 
of  the  first  week.  Even  if  the  tendon  will  not  remain  re- 
duced, a  useful  joint  will  be  obtained.  Wood  of  New  York 
advised  in  obstinate  cases  tenotomy  and  immobilization. 

Wounds  of  Tendons. — Subcutaneous  wounds  of  ten- 
dons are  usually  inflicted  by  the  surgeon,  and  they  heal  well. 
Open  wounds  require  rigid  antisepsis  and  the  suturing  of  the 
tendon.  In  wounds  of  the  wrist  especially  always  suture  the 
tendons  (Fig.  149),  and  be  sure  to  bring  the  proper  ends  into 
apposition. 

Rupture  of  Tendons. — A  violent  muscular  effort  may 
rupture  a  tendon,  and  a  snap  may  often  be  heard.  The  symp- 
toms are  sudden  pain  and  loss  of  power,  fulness  of  the  asso- 
ciated muscle  from  retraction,  and  absolute  inability  to  bring 
the  tendon  into  action.  A  gap  may  often  be  felt  in  the  tendon. 

Treatment. — The  best  procedure  in  treating  rupture  of  a 
tendon  is  incision  and  tendon-suture.  Some  surgeons  relax 
the  parts  and  apply  splints. 

Thecitis  or  tenosynovitis  is  inflammation  of  the  sheath 
of  a  tendon. 

Acute  thecitis  may  arise  from  a  contusion,  from  a 
wound,  from  repeated  over-action  in  working,  from  rheu- 
matism, from  gonorrhea,  from  influenza,  from  the  continued 
fevers,  or  from  syphilis.  In  early  syphilis  certain  tendon 
sheaths  may  rapidly  develop  effusion  because  of  hyperemia 
of  the  sheaths  (Taylor). 

Symptoms. — In  nonsuppurative  cases  of  thecitis  the 
symptoms  are  pain,  swelling,  tenderness,  and  moist  crep- 
itus along  the  tendon-sheath,  due  to  inflammatory  rough- 
ening. The  crepitus  disappears  as  the  swelling  increases, 
but  it  reappears  as  the  swelling  diminishes.  In  suppurative 
cases  the  symptoms  are  great  swelling,  pulsatile  pain,  dusky 
discoloration,  inflammation  spreading  up  the  tendon-sheaths, 
and  the  constitutional  symptoms  of  sepsis. 

Treatment. — In  treating  non-suppurative  thecitis,  employ 

^  Walsham's  case  of  dislocation  of  peroneus  longus,  Brit.  Med.  Joiir.,  Nov.  2, 
1895- 


DISEASES  AND   INJURIES   OF  MUSCLES,   ETC.         511 

splints  and  apply  locally  iodin,  blue  ointment,  or  ichthyol. 
Treat  any  causative  constitutional  state.  In  the  suppurative 
form  make  free  incisions,  irrigate,  and  drain. 

Palmar  Abscess. — A  thecal  abscess  about  the  flexor 
tendons  of  the  fingers  travels  rapidly  upward  and  is  apt  to 
produce  a  palmar  abscess.  A  thecal  abscess  of  either  the  in- 
dex ring  or  middle  finger  is  usually  arrested  at  the  lower  end 
of  the  palm,  but  suppurative  thecitis  of  the  thumb  or  the  little 
finger  diffuses  pus  over  a  large  surface  of  the  palm  and  also 
up  the  arm.  Palmar  abscess  is  a  most  serious  affection. 
The  pus  may  dissect  up  all  the  structures  of  the  palm,  may 
reach  the  dorsum,  or  may  pass  beneath  the  anterior  annular 
ligament  into  the  connective-tissue  planes  of  the  forearm. 

Treatment. — A  palmar  abscess  demands  free  incision  and 
drainage  at  the  earliest  possible  moment.  The  incision  is 
made  in  the  line  of  the  metacarpal  bone  and,  if  possible, 
below  the  palmar  arches.  A  line  transverse  with  the  web 
of  the  thumb  is  below  the  palmar  arches.  In  an  incision 
above  this  line,  try  not  to  cut  either  arch ;  but  if  one  be  cut, 
at  once  take  means  to  arrest  the  hemorrhage  (page  263). 

Chronic  thecitis  may  follow  an  acute  thecitis,  but  may 
be  due  to  injury,  to  rheumatism,  to  gummatous  infiltration,  to 
rheumatoid  arthritis,  or  to  a  tubercular  inflammation  of  a 
tendon-sheath.  In  tubercular  thecitis  the  swelling  is  firm  or 
doughy  when  due  to  granulation-tissue,  but  is  fluctuating 
when  due  to  fluid.  Grating  is  marked.  The  tendon-sheath 
may  contain  numerous  small  bodies  which  are  either  free  or 
are  attached  (rice,  riziform,  or  melon-seed  bodies).  Tubercle 
bacilli  are  present  in  the  fluid  or  in  the  granulation-tissue. 
Chronic  thecitis  is  commonest  in  the  tendons  of  the  fingers, 
the  ankle,  and  the  knee ;  it  may  spread  to  a  joint,  or  it  may 
arise  from  a  tubercular  joint.  This  condition  causes  very 
little  pain.  In  ordinary  non-tubercular  thecitis  the  part  is 
weak,  tender,  painful,  and  stiff,  crepitates  on  motion,  and  is 
swollen. 

Treatment. — Tubercular  cases  are  treated  as  follows :  in 
cases  in  which  there  is  fluid  effusion  make  a  small  incision, 
wash  out  with  iodoform  emulsion,  and  close  the  wound.  In 
cases  in  which  there  are  rice-bodies,  open  the  sheath,  evacuate 
the  contents,  scrape  the  walls  thoroughly,  inject  with  iodo- 
form emulsion,  and  close  the  wound.  (If  the  annular  liga- 
ment is  divided,  stitch  it  together;  Fig.  152).  In  cases  with 
extensive  formation  of  embryonic  tissue  apply  an  Esmarch 
bandage,  make  a  large  incision,  and  remove  all  infected  tis- 
sue from  the  sheath,  around  the  sheath,  and  from  the  ten- 


512  MODERN  SURGERY. 

don.  In  an  ordinary  traumatic  case  employ  hot  and  cold 
douches,  massage,  and  passive  movements,  strapping  of  the 
part,  inunctions  of  ichthyol,  and  the  hot-air  bath.  If 
effusion  is  persistent  or  rice-bodies  exist,  make  an  incision 
and  scrape  out  the  tendon-sheath.  In  rheumatic  cases  give 
anti-rheumatic  remedies  and  employ  the  hot-air  bath.  In 
syphilitic  cases  administer  mercury  and  iodid  of  potassium. 

Ganglia. — In  connection  with  tendon-sheaths  simple 
gangha  may  develop.  They  are  small,  tense,  round  swell- 
ings, which  are  firm,  grow  progressively  though  slowly,  are 
painless  when  uninflamed,  and  contain  a  fluid  of  the  appear- 
ance and  consistence  of  glycerin  jelly  (Bowlby).  These  gan- 
glia are  commonest  upon  the  dorsum  of  the  wrist,  and  they 
occur  especially  in  those  who  constantly  use  the  wrist-mus- 
cles. Paget  states  that  a  simple  ganglion  is  due  to  cystic 
degeneration  of  a  synovial  fringe  inside  a  tendon-sheath,  and 
that  the  fluid  of  the  ganglion  does  not  communicate  with  the 
fluid  of  the  tendon-sheath.  Other  pathologists  believe  a  sim- 
ple ganglion  to  be  a  hernia  of  synovial  membrane  through  a 
rent  in  a  tendon-sheath,  all  communication  between  the  her- 
niated part  and  the  tendon-sheath  being  soon  obliterated. 
Compound  ganglion  is  an  old  name  for  tubercular  thecitis. 

Treatment. — Ganglia  are  treated  by  aseptic  puncture  with 
a  tenotome,  evacuation,  scarification  of  the  walls,  antiseptic 
dressing,  and  pressure.  An  old-time  method  of  treatment 
was  subcutaneous  rupture  brought  about  by  striking  with  a 
heavy  book.  Duplay  treats  a  ganglion  by  injecting  a  few 
drops  of  iodin  through  a  hypodermatic  needle.  The  cyst  is 
not  evacuated  before  injection.  The  parts  are  dressed  anti- 
septically,  and  cure  is  obtained  in  one  week.  Recurrent 
ganglia,  very  large  ganglia,  and  ganglia  with  very  thick 
contents  should  be  dissected  out. 

Felon,  or  whitlow,  is  a  violent  inflammation  of  a  finger 
or  a  toe  which  leads  to  rapid  suppuration  and  sometimes  to 
gangrene.  As  a  rule,  an  injury  precedes  the  whitlow,  an 
abrasion  of  the  surface  which  admits  pus  organisms  or  a 
contusion  which  creates  a  point  of  least  resistance.  The 
commonest  seat  of  a  felon  is  the  last  digit  of  the  finger  or 
thumb.  An  abrasion  of  the  surface  at  this  point  absorbs  pus 
organisms  and  the  superficial  lymphatics  carry  them  directly 
inward,  lodging  them,  it  may  be,  in  the  subcutaneous  tissues, 
or  it  may  be  beneath  the  periosteum. 

Felons  are  very  rare  in  infants,  but  may  occur  in  children. 
Women  are  more  liable  to  them  than  are  men.  Several 
fingers  may  be  attacked  at  once  or  successively  in  persons 


DISEASES  AND   INJURIES   OF  MUSCLES,   ETC.         513 

of  dilapidated  constitution.  In  certain  cases  of  neuritis 
painless  suppuration  may  arise. 

There  are  two  forms  of  felons,  the  superficial  and  the  deep. 

Superficial  felon,  or  paronychia,  is  a  cellulitis  starting  at 
the  end  or  side  of  the  digit,  and  involving  the  parts  around 
and  below  the  nail.  The  pus  organisms  obtain  entrance  by 
means  of  an  abrasion,  a  puncture,  or  an  ulcerated  "  step- 
mother," The  pain  is  throbbing  and  violent ;  is  increased  by 
motion,  pressure,  or  a  dependent  position ;  the  skin  is  dusky 
red,  but  the  swelling  is  slight.  In  about  forty-eight  hours 
pus  forms  in  the  superficial  parts,  the  epidermis  being  lifted 
into  pustules  or  blebs,  and  pus  may  also  form  under  the  nail. 
A  portion  of  the  nail,  or  the  entire  nail,  may  be  lost. 

Deep  felon,  or  bone-felon,  involves  most  of  the  structures 
of  the  finger  (periosteum,  bone,  tendon,  tendon-sheath,  and 
cellular  tissue),  and  may  destroy  the  digit  or  the  finger.  It 
arises  in  the  same  manner  as  paronychia,  but  the  organisms 
are  lodged  in  the  deeper  parts.  The  pain  is  agonizing,  en- 
tirely preventing  sleep,  pulsatile  in  character,  associated  with 
excruciating  tenderness,  greatly  aggravated  by  motion  or  a 
dependent  position,  and  often  extending  up  the  hand  and 
forearm.  The  skin  is  red  and  edematous,  and  the  part  is 
enormously  swollen.  Pus  forms  quickly ;  diffuse  cellulitis 
may  arise;  thecal  suppuration  may  occur;  sloughing  of  the 
tendon  and  subcutaneous  tissue  may  take  place  ;  necrosis  of 
one  or  more  bones  may  ensue,  and  in  some  cases  gangrene 
of  the  finger  follows. 

In  deep  whitlow  lymphangitis  of  the  forearm  and  arm  is  not 
unusual,  adenitis  of  the  axillary  glands  is  common,  and  almost 
always  there  is  fever.  In  superficial  felon  constitutional 
symptoms  are  slight  or  absent,  and  lymphangitis  and 
adenitis  arise  in  a  minority  of  cases. 

Treatment. — A  superficial  felon  demands  instant  incision 
in  all  cases,  and  the  parts  are  irrigated  and  dressed  with 
hot  antiseptic  fomentations.  A  bone-felon  should  be  incised 
at  once  to  the  bone  alongside  the  tendon.  Do  not  wait 
for  pus  to  form,  but  allay  tension  and  prevent  pus-formation 
by  early  incision.  Do  not  waste  time  with  poultices  :  to 
wait  means  agonizing  pain,  sleepless  nights,  constitutional 
involvement,  and  perhaps  sloughing  of  tendons  or  death 
of  the  bone.  Incision  and  drainage  constitute  the  treatment, 
followed  by  irrigation,  antiseptic  fomentations,  and  splinting 
of  the  extremity.  If  the  patient  cannot  sleep,  give  morphin. 
See  that  the  bowels  are  moved  once  a  day.  Give  quinin, 
iron,  and  milk  punch.  Opening  a  felon  is  exquisitely  pain- 
33 


5  1 4  MODERN  SURGER  K 

ful ;  hence  ether  should  be  given  to  the  first  stage,  nitrous 
oxid  should  be  administered,  or  the  superficial  parts  should 
be  firozen  by  a  spray  of  chlorid  of  ethyl. 

Bursitis  is  inflammation  of  a  bursa.  Acute  bursitis 
arises  from  strain  or  from  traumatism.  The  symptoms  of 
acute  bursitis  are  pain,  limited  swelling,  moist  crepitus,  fluct- 
uation, and  discoloration  in  the  anatomical  position  of  a 
bursa.  Bursitis  of  the  retrocalcaneal  bursa  (Albert's  disease) 
is  a  painful  affection  which  is  often  overlooked.  Walking 
causes  great  pain  in  the  heel.  Raising  up  on  the  toes  is 
excessively  painful.  It  is  usually  associated  with  flat  foot. 
In  these  cases  osteophytes  often  form  within  the  bursa. 
Bursitis  of  the  gluteal  bursae  produces  symptoms  resem- 
bling those  of  incipient  coxalgia.  But  in  bursitis  the  symp- 
toms do  not  remit  as  in  hip  disease.  There  is  moderate  pain 
back  of  the  leg  and  knee  which  disappears  when  the  patient 
is  at  rest ;  there  is  marked  limp,  limitation  of  motion,  and  an 
area  of  deep  fluctuation  in  the  buttock  (Brackett). 

It  is  difficult  to  separate  bursitis  of  any  deep  bursa 
from  synovitis ;  indeed,  the  joint  is  apt  to  become  sec- 
ondarily affected.  This  difficulty  is  especially  vexatious  in 
distinguishing  between  joint-injury  and  injury  of  the  bursa 
beneath  the  deltoid.  Suppuration  may  take  place.  Direct 
force  may  rupture  a  bursa.  When  this  accident  happens 
there  are  pain,  marked  swelling,  a  large  area  of  moist  crepitus, 
and  later  extensive  discoloration  from  blood.  Chronic  bur- 
sitis may  follow  acute  bursitis,  or  the  disease  may  be  chronic 
from  the  start.  Its  symptom  is  swelling  with  little  or  no  pain 
unless  acute  inflammation  arises.  Chronic  bursitis  of  the  sub- 
hyoid bursa  is  known  as  Boyer's  cyst. 

Treatment. — Acute  bursitis  is  treated  at  first  by  rest  and 
pressure  and  with  lead-water  and  laudanum ;  later  with 
iodin,  blue  ointment,  or  ichthyol.  If  the  swelling  persists, 
aspirate.  If  pus  forms,  incise,  swab  out  the  sac  with  pure 
carbolic  acid,  and  pack  it  with  iodoform  gauze.  A  chronic 
bursitis  may  get  well  from  the  use  of  pressure,  as  the  appli- 
cation of  blue  ointment,  with  treatment  of  any  causative 
diathesis ;  but  most  cases  require  incision  and  packing.  A 
ruptured  bursa  is  treated  as  an  acute  bursitis.  Some  cases 
of  retrocalcaneal  bursitis  get  well  from  rest,  but  others 
demand  incision  and  drainage.  If  osteophytic  formation 
takes  place  in  Albert's  Disease  remove  the  bony  stalactites 
with  a  rongeur  forceps  or  a  gouge. 

Housemaid's  knee  is  thickening  and  enlargement  of  the 
prepatellar  bursa,  due  to  intermittent  pressure.     In  effusion 


DISEASES  AND   INJURIES   OF  MUSCLES,   ETC.         515 

into  the  knee-joint  the  fluid  is  behind  the  patella  and  the 
bone  floats  up ;  in  housemaid's  knee  the  fluid  is  above 
the  bone  and  the  osseous  surface  can  be  felt  beneath  it. 
"  Miners'  elbow,"  which  is  a  condition  similar  to  housemaid's 
knee,  affects  the  olecranon  bursa.  "  Weavers'  bottom "  is 
enlargement  of  the  bursa  over  the  tuberosity  of  the  ischium. 
A  bursa  which  is  simply  thickened  and  enlarged  rarely  gives 
rise  to  annoyance ;  but  when  it  inflames,  as  it  is  apt  to  do,  it 
causes  the  ordinary  symptoms  of  bursitis. 

Treatment. — Housemaid's  knee  is  treated  by  incision  and 
packing  with  iodoform  gauze.  In  enlargement  of  the  bursa 
beneath  the  ligamentum  patellae,  if  rest  and  blistering  fail  to 
cure,  aspirate  or  incise.  In  enlargement  of  the  bursa  below 
the  tendon  of  the  semimembranosus  and  also  in  "  weavers' 
bottom  "  incise  and  pack. 

Bunion. — A  bunion  is  a  bursa  due  to  pressure,  and  it  is 
most  commonly  found  above  the  metatarsophalangeal  articu- 
lation of  the  great  toe,  but  is  occasionally  seen  over  the  joint 
of  another  toe.  When  the  big  toe  is  pushed  inward  by  ill- 
fitting-  boots  a  bunion  forms.  When  a  bunion  is  not  in- 
flamed  it  may  cause  but  little  trouble,  but  when  it  is  mflamed 
the  bursa  enlarges  and  the  parts  become  hot,  tender,  and 
excessively  painful.  Suppuration  may  occur  and  pus  may 
invade  the  joint,  and  the  bone  not  unusually  becomes  dis- 
eased. 

Treatment. — In  treating  a  bunion  the  patient  must  wear 
shoes  that  are  not  pointed,  that  have  the  inner  borders 
straight,  and  that  have  rounded  toes  (Jacobson).  For  a 
mild  case  a  bunion-plaster  gives  comfort.  Sayre  advises 
the  use  of  a  linen  glove  over  the  phalanges,  which  are  to  be 
drawn  inward  by  a  piece  of  elastic  webbing  one  end  of  which 
is  fastened  to  the  glove  and  the  other  end  to 
a  piece  of  strapping  from  the  heel,  A  special 
apparatus  may  be  worn  (Fig.  148).  In  many 
cases  osteotomy  of  the  first  phalanx  or  of  the 
first  metatarsal  bone  is  required ;  in  some 
cases  excision  of  the  joint  is  necessary ;  in 
others  amputation  must  be  performed.  When 
the  bursa  is  not  inflamed,  but  only  thickened, 
blisters  should  be  employed  over  it,  or  there        .,       op-. 

.       i^       •'  .        '  tlG.  148. — Biggs 

should  be  applied  tincture  of  iodin,  ichthyol,     apparatus  for  bun- 
or  mercurial  ointment.     When  the  bursa  in- 
flames, lead-water  and  laudanum  is  applied,  and  intermittent 
heat  by  foot-baths  gives  relief     Suppuration  demands  im- 
mediate incision  and  antiseptic  dressing.      If  an   ulcerated 


5  1 6  MODERN  SUR GER  Y. 

bunion  does  not  heal  by  antiseptic  dressing,  stimulate  it  with 
silver  and  dress  it  with  unguent,  hydrarg.  nitrat.  (i  part  to  7 
of  cosmolin).  Jacobson  recommends  skin-grafting  for  some 
cases. 

Operations  upon  Muscles  and  Tendons. 

Tenotomy  is  the  cutting  of  a  tendon.  It  may  be  open 
or  subcutaneous,  the  open  operation  being  preferred  in  dan- 
gerous regions. 

Division  of  the  Sterno-cleido-mastoid  Muscle  for 
Wry-neck. — Subcutaneous  tenotomy  has  been  abandoned. 
It  is  not  only  more  unsafe  than  the  open  operation,  but  it 
never  completely  divides  all  of  the  thickness  of  the  con- 
tracted band. 

The  instruments  required  consist  of  a  scalpel,  dissecting- 
forceps,  hemostatic  forceps,  scissors,  needles,  ligatures,  etc. 
The  patient  is  placed  recumbent,  the  chin  being  drawn  more 
toward  the  opposite  side. 

A  transverse  incision  is  made  over  the  muscle  about  one- 
fourth  of  an  inch  above  the  clavicle.  The  superficial  parts 
are  divided,  the  muscle  is  exposed  and  sectioned,  bleeding 
is  arrested,  and  the  skin  is  sutured.  Avoid  the  anterior 
jugular  vein,  which  is  underneath  the  muscle,  and  also  the 
external  jugular,  which  is  close  to  the  outer  edge  of  the 
muscle.  Mikulicz  advocates  the  removal  of  almost  the 
entire  muscle,  leaving,  however,  the  upper  and  posterior 
portion  where  the  spinal  accessory  nerve  passes.  After 
operation  for  wry-neck  support  the  head  with  sand  bags 
until  healing  occurs,  and  then  inaugurate  motions  active  and 
passive. 

Subcutaneous  Tenotomy  of  the  Tendo  Achillis. — 
This  operation  is  performed  for  club-foot,  in  which  the  heel 
is  raised.  The  tendon  is  cut  about  one  inch  above  its  point 
of  insertion.  The  instrument  used  for  the  first  puncture  is  a 
sharp  tenotome.  The  patient  lies  upon  his  back  "  with  his 
body  rolled  a  little  toward  the  affected  side  "  (Treves),  the 
foot  being  placed  upon  its  outer  side  on  a  sand  pillow.  The 
surgeon  stands  to  the  outside.  The  tendon  is  rendered 
moderately  rigid,  and  the  sharp  tenotome,  with  its  blade 
turned  upward,  is  inserted  along  the  anterior  border  of  the 
tendon  until  the  surgeon's  finger  feels  the  knife  approaching 
the  outer  side.  A  blunt-pointed  tenotome  is  inserted  in  place 
of  the  sharp  instrument.  The  tendon  is  drawn  into  rigid- 
ity, and  the  surgeon  turns  the  blade  of  his  knife  toward  the 


DISEASES  AND   INJURIES   OF  MUSCLES,   ETC.         517 

tendon,  places  his  finger  over  the  skin,  and  saws  toward  his 
finger.  The  tendon  gives  way  with  a  snap.  Treves  states 
that  a  beginner  is  apt  not  to  push  the  knife  far  enough 
toward  the  outside,  or  he  may  in  the  first  puncture  push 
the  knife  through  the  tendon  ;  in  either  case  the  tendon  is 
not  completely  cut.  The  little  wound,  which  is  covered 
with  a  bit  of  gauze,  will  be  entirely  closed  in  forty-eight 
hours.  In  club-foot  cases  after  tenotomy  some  surgeons 
at  once  correct  the  deformity  and  immobilize  the  limb  in 
plaster ;  some  partially  correct  the  deformity  and  apply 
plaster  for  one  week,  at  which  time  they  remove  the  plaster, 
correct  the  deformity  further,  reapply  the  plaster,  and  so  on  ; 
other  surgeons  do  not  attempt  correction  of  the  deformit}' 
until  the  cut  tendon  has  begun  to  unite,  when  they  gradually 
stretch  the  new  material. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the 
Tibialis  Anticus. — The  tendon  is  divided  about  one  and 
a  half  inches  above  its  point  of  insertion.  It  can  be  made 
tense  by  extending  and  abducting  the  foot.  The  sharp- 
pointed  tenotome  is  entered  upon  the  outside  of  the  tendon, 
and  is  passed  well  around  it.  The  blunt-pointed  tenotome 
is  used  to  cut  the  tense  tendon. 

Subcutaneous  Tenotomy  of  the  Tendons  of  the 
Peroneus  I/OngUS  and  Brevis. — These  two  tendons  are 
cut  together  back  of  the  external  malleolus,  and  one  and  a 
half  inches  above  the  tip  of  the  malleolus,  so  as  to  avoid  the 
synovial  sheath  (Treves).  The  patient  lies  upon  the  sound 
side,  the  outer  aspect  of  the  deformed  foot  being  upward  and 
the  inner  aspect  of  the  ankle  of  the  deformed  side  resting 
upon  a  sand  pillow^  The  instrument  is  introduced  close  to 
the  fibula,  and  is  carried  around  the  loose  tendons.  A  blunt- 
pointed  tenotome  is  now  introduced,  its  edge  is  turned 
toward  the  tendons,  and  these  structures  are  cut  as  they 
are  made  tense. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the 
Tibialis  Posticus. — This  tendon  is  sectioned  above  the 
point  where  its  synovial  sheath  begins  ;  that  is,  above  the 
internal  annular  ligament  (Treves).  The  tendon  is  made 
tense  and  the  knife  is  entered  above  the  base  of  the  inner 
malleolus.  The  knife  is  entered  just  back  of  the  inner  edge 
of  the  tibia,  and  is  carried  around  the  muscle  while  it  is  kept 
close  to  the  bone.  The  tendon  is  sectioned  with  a  blunt 
knife. 

Subcutaneous  Fasciotomy  of  Plantar  Fascia. — 
The   contracted    bands    are    discovered    by   motions    which 


5i8 


MODERN  SURGERY. 


render  them  tense,  and  they  are  divided  just  in  front  of  the 
attachment  to  the  os  calcis.  The  sharp  knife  passes  between 
the  skin  and  fascia  at  the  inner  side  of  the  sole  of  the  foot. 
The  fascia  is  cut  from  without  inward  by  the  blunt-pointed 
tenotome.  It  is  usually  necessary  to  section  the  fascia  at 
more  than  one  point. 

Tendon-suture  and  Tendon-lengthening. — The  in- 
struments required  in  these  operations  are  an  Esmarch  appa- 
ratus ;  curved  needles  and  needle-holder ;  chromicized  gut, 
kangaroo-tendon,  or  silk  for  an  ordinary  case,  silver  wire  for 
a  suppurating  wound.  In  performing  tendon-suture  make 
the  part  aseptic  and  bloodless.  It  is  wise  to  apply  a  rubber 
bandage  on  the  proximal  side,  the  bandage  being  applied 
centrifugally,  forcing  the  proximal  end  of  the  tendon  into 
view  (Haegler).  If  searching  for  the  proximal  end  of  a 
flexor  of  the  finger,  flex  the  injured  finger,  and  hyper- 
extend  the  adjoining  fingers  (Filiget).  If  this  expedient  fails, 
enlarge  the  incision,  or,  what  is  better,  make  a  large  flap  in 
the  skin.  After  finding  the  ends  approximate  them,  being 
sure  the  proper  ends  are  brought  into  contact ;  stitch  them 
together  with  a  continuous  suture  or  with  one  of  the  sutures 
shown  in   Fig.  149,  a,  b,  and  c.     In  a  suppurating  wound 


B-i 


L 


1 


Fig.  149. — Tendon-sutures  :  a.  of  Le  Fort ; 
B,  of  Le  Dentu ;  c,  of  Lejars. 


Fig.  150. — Anderson's  method  of  tendon- 
lengthening. 


suture  by  silver  wire  should  be  tried,  though  it  usually  fails. 
After  suturing,  remove  the  Esmarch  apparatus,  arrest  bleed- 
ing, close  the  wound  and  dress  it  antiseptically,  relax  the 
parts,  and  place  the  Hmb  on  a  splint.  If,  after  suturing, 
there  is  much  tension,  stitch  the  cut  tendon  above  the 
sutures  to  an  adjacent  tendon,  and  apply  a  splint,  the  finger 
which  was  injured  being  flexed,  the  others  being  extended. 
If  only  the  distal  end  of  the  tendon  can  be  found,  graft  it 
upon  the  nearest  tendon  with  a  like  anatomical  course  and 
function.     When  a  tendon  has  been  sutured  begin  gentle 


ORTHOPEDIC  SURGERY.  519 

massage  in  two  weeks.  Positive  passive  motion  is  begun 
in  three  or  four  weeks.  In  old  inju- 
ries, when  the  ends  cannot  be  brought 
into  apposition,  lengthen  one  end  or 
both  ends,  either  by  the  method  of 
Anderson  (Fig.  1 50)  or  by  the  method 
of  Czerny  (Fig.  151).     Poncet  makes 


F:g.  152. — Method  of  suturing 
the    annular    ligament    of     the 
Fig.  151. — Czerny 's  method  of  tendon-lengthening.  wrist. 

several  zigzag  incisions  on  each  side  of  the  tendon,  and 
when  the  tendon  is  pulled  upon  it  elongates  decidedly. 
These  methods  of  lengthening  may  be  used  in  cases  of  de- 
formity from  a  contracted  tendon.  If  the  tendon  cannot  be 
lengthened  sufficiently,  make  a  bridge  of  catgut  from  one 
end  of  it  to  the  other,  or  graft  in  another  tendon  from  the 
same  person  or  from  one  of  the  lower  animals. 

The  annular  ligament  is  sutured  as  shown  in  Fig.  152. 

In  some  cases  in  which  a  muscle  has  been  paralyzed, 
Nicoladoni  and  others  have  divided  the  tendon  of  the  para- 
lyzed muscle  and  have  united  its  distal  end  with  the  tendon 
of  a  normal  muscle,  the  normal  tendon  being  split  to  re- 
ceive it. 

XXI.  ORTHOPEDIC  SURGERY. 

This  branch  of  surgery  formerly  dealt  only  with  the  treat- 
ment of  deformities  by  means  of  mechanical  appliances,  but 
of  recent  years  its  domain  has  been  enlarged  to  include  the 
treatment,  surgical  and  mechanical,  of  deformities,  contract- 
ures, and  many  joint-diseases. 

Torticollis  (wry-neck)  is  a  condition  in  which  contrac- 
tion of  certain  of  the  neck-muscles  causes  an  alteration  in 
the  position  of  the  head.  The  disease  is  one-sided ;  the 
sterno-cleido-mastoid  is  the  muscle  chiefly  involved,  though 
the  trapezius,  splenius,  and  other  muscles  sometimes  suffer. 
Acute  torticollis,  which  is  rare,  results  from  cold  or  from 
injury  (see  Myalgia).  Chronic  torticollis  may  be  congenital, 
it  may  be  due  to  nerve-irritation,  or  it  may  be  due  to  an 
assumed  attitude  because  of  eye-defect.  Chronic  torticollis 
may  be  intermittent,  but  is  usually  persistent.  The  muscle 
stands  out  in  bold  outline,  the  head  is  turned  to  the  oppo- 
site side,  the  ear  of  the  disordered  side  is  turned  toward  the 
shoulder,  and  the  chin  is  thrown  forward.  There  is  no  pain. 
Spinal  curvature  may  arise.     The  head  may  often  be  restored 


520  MODERN  SURGERY. 

to  its  normal  position  by  passive  movement  or  by  voluntary 
effort,  but  it  at  once  returns  to  its  habitual  position.  The 
corresponding-  side  of  the  face  atrophies.  MikuHcz  asserts 
that  torticollis  is  a  chronic  fibrous  myositis,  due  often  to 
compression  during  labor.  He  further  says  that  the  lesion 
known  as  hematoma  of  the  sternomastoid,  which  occasionally 
follows  labor,  is  not  hematoma,  but  thickening  due  to  myositis. 

Symptoms. — Congenital  wry-neck  is  due  to  central  ner- 
vous disease,  to  spinal  deformity,  or  to  injury  during  birth, 
and  in  this  form  the  sternomastoid  is  shortened,  hardened, 
and  atrophied.  It  may  not  be  noticed  for  some  years  be- 
cause of  the  short  neck  of  infancy,  and  it  is  associated  with 
asymmetrical  development  of  the  face.  It  is  almost  inva- 
riably upon  the  right  side.  Spasmodic  wry-neck  may  present 
tonic  spasm  only,  intermittent  spasm  alone,  or  both  may 
appear  alternately.  It  is  a  disease  especially  of  adults ;  in 
women  it  is  often  linked  with  hysteria.  The  exciting  cause 
may  be  a  cold,  a  blow,  or  a  mental  storm ;  the  predisposing 
cause  is  the  neurotic  temperament.  In  some  rare  cases 
bilateral  spasm  occurs,  the  head  being  pulled  backward  and 
the  face  being  turned  upward.  Clonic  spasms  may  come 
on  unannounced,  or  they  may  be  preceded  by  pain  and 
stiffness ;  the  head  can  be  held  still  for  a  moment  only ; 
there  is  sometimes  pain,  always  fatigue,  but  during  sleep  the 
contractions  cease.  The  attack  will  probably  pass  away,  but 
will  almost  certainly  recur. 

Treatment. — Congenital  wry-neck  is  treated  by  myo- 
tenotomy (through  an  open  wound)  and  the  use  of  proper 
braces  and  supports.  The  old  subcutaneous  myotenotomy 
should  be  abandoned,  as  aseptic  incision  enables  the  surgeon 
to  see  and  to  feel  all  the  contracted  bands  of  fascia,  muscle, 
and  tendon,  and  to  avoid  vital  structures  (page  516).  In 
spasmodic  wry-neck  treat  the  neurotic  temperament ;  in  per- 
sistent cases  stretch,  or  divide  and  exsect  a  part  of  the 
spinal  accessory  nerve.  To  reach  this  nerve  make  an  in- 
cision along  the  posterior  edge  of  the  sternocleidomastoid, 
find  the  nerve  as  it  emerges  from  under  the  middle  of  the 
muscle,  and  retract  the  muscle  at  this  point  (Keen).  For 
the  treatment  of  rheumatic  wry-neck  see  Myalgia  (page  504). 

Dupuytren's  contraction  is  a  contraction  of  the  palmar 
fascia,  of  its  digital  prolongations,  and  of  the  fibers  joining 
the  fascia  and  skin.  Fixed  contraction  of  one  or  more 
fingers  occurs.  The  ring-finger  and  the  little  finger  most 
often  suffer.  The  condition  may  be  symmetrical.  The  dis- 
ease arises  oftenest  in  men  beyond  middle  age.     The  cause 


ORTHOPEDIC  SURGERY. 


521 


of  this  disease  is  unknown  :  some  refer  it  to  gout  or  rheu- 
matism, others  to  traumatism,  reflex  irritation,  or  neuritis. 

Symptoms. — Dupuytren's  contraction  is  indicated  by  a 
small  hard  lump  or  crease  which  appears  over  the  palmar 
surface  of  the  metacarpophalangeal  joint.  This  nodule 
grows  and  the  corresponding  finger  is  pulled  down.  In 
some  cases  the  tip  of  the  finger  is  forced  against  the  palm. 
The  skin  becomes  dimpled  or  puckered. 

Treatment. — In  treating  Dupuytren's  contraction  subcu- 
taneous multiple  incisions  may  be  made,  the  tense  fascia  and 
the  fasciocutaneous  fibers  being  cut.  The  finger  is  straight- 
ened and  is  placed  upon  a  straight  splint,  which  is  worn 
continuously  for  a  week  or  ten  days  and  is  worn  at  night  for 
at  least  a  month.  Keen  divides  the  skin  by  a  V-shaped 
cut,  the  base  oi  the  V  being  downward,  lifts  up  the  flap, 
and   dissects    out  the  contracted  tissue. 

Syndactylism  (webbed  fingers)  is  always  congenital, 
and  may  persist  through  several  generations.  Simple  incision 
of  the  web  is  useless ;  the  operation  to  be  performed  is  that 
of  Agnew  or  of  Diday  (Figs.  153,  154). 

In  Agnew's  operation  a  flap  of  skin  from  the  dorsum  is 
inserted  between  the  fingers. 

In  Diday's  operation  a  flap  is  taken  from  the  dorsal  sur- 
face and  another  flap  is  raised  from  the  palmar  surface,  and 
each  flap  is  sutured  to  the  finger  from  which  it  springs. 


Fig.  153. — Agnew's  operation  for  webbed 
fingers  (Pye). 


Fig.  154. — Diday's  operation  for 
webbed  fingers  (Pye). 


Polydactylism  (supernumerary  digits)  is  always  con- 
genital, is  often  hereditary,  and  is  usually  symmetrical. 
There  may  be  an  incomplete  digit,  or  there  may  be  an  entire 
and  well-developed  finger  or  toe  with  a  metacarpal  or  meta- 
tarsal bone.  The  connection  to  the  metatarsus  or  metacar- 
pus may  be  by  a  fibrous  pedicle  only.  If  the  digit  is  com- 
plete, with  a  metacarpal  bone,  no  operation  is  required ;  if  it 
is  incomplete  or  is  ill-developed,  it  should  be  remov^ed. 

Trigger-finger  or  Jerk-finger. — The  patient  can  close 
the  fingers,  but  on  trying  to  open  them  one  finger  remains 


522  MODERN  SURGERY. 

closed.  It  can  be  opened  by  grasping  it  with  the  other 
hand,  but  flies  open  with  a  snap  hke  an  opening  knife  (Abbe). 
The  condition  is  due  to  enlargement  of  the  flexor  tendon,  or 
to  contraction  of  the  groove  in  the  transverse  ligament  in 
the  palm  (Tubby).  This  condition  may  be  due  to  ganglion, 
enchondroma,  or  tenosynovitis. 

Treatment. — If  a  trauma,  a  ganglion,  or  inflammation  exists, 
treat  by  ordinary  means.  If  there  is  no  obvious  cause,  put  a 
compress  over  the  tunnel  in  the  ligament  and  apply  a  splint. 

Mallet-finger. — This  is  called  also  drop-finger  and  rupt- 
ure of  the  extensor  tendon.  It  is  due  to  a  blow  in  the  direc- 
tion of  flexion  when  the  finger  is  extended.  It  is  supposed  to 
be  due  partly  to  stretching  and  partly  to  rupture  of  the  ex- 
tensor tendon  at  the  point  at  which  it  is  the  posterior  liga- 
ment of  the  distal  interphalangeal  joint.  Abbe  has  shown 
that  baseball  players  are  Hable  to  a  condition  which  is  the 
reverse  of  this,  in  which  the  last  phalanx  is  dislocated  back- 
ward. Drop-finger  is  treated  by  incision  and  suture  of  the 
tendon  to  the  periosteum  (Abbe). 

Genu  valgum  (knock-knee)  results  from  an  unnatural 
growth  of  the  internal  condyle,  causing  the  shaft  of  the 
femur  to  curve  inward  and  the  internal  lateral  ligament  of 
the  knee-joint  to  stretch,  the  knees  coming  close  together 
and  the  feet  being  widely  separated.  This  deformity  is  usu- 
ally noted  when  the  child  begins  to  walk,  but  it  may  not 
appear  until  puberty  or  even  long  after.  Knock-knee  may 
arise  from  rickets,  from  an  occupation  demanding  prolonged 
standing,  or  from  flat-foot.  It  may  be  noted  in  one  knee  or 
in  both  knees. 

Treatment. — Mild  rachitic  cases  of  knock-knee  may  re- 
main in  slight  deformity,  or  may  get  well  from  improvement 
of  the  general  health.  In  ordinary  cases  simply  treat  the 
rickety  condition.  The  patient  is  forbidden  to  stand  or  to 
walk,  and  the  limb,  after  being  put  as  straight  as  it  can  be, 
is  fixed  on  an  external  splint  and  a  pad  is  put  over  the 
inner  condyle.  Later  in  the  case  plaster-of-Paris  is  used. 
Some  surgeons  prefer  to  immobilize  while  the  leg  is  flexed 
to  a  right  angle  Avith  the  thigh.  In  a  severe  case  the  sur- 
geon can  immobilize  after  forcibly  straightening  (causing  an 
epiphyseal  separation)  or  after  the  performance  of  osteotomy 
(Fig.  127).  Osteotomy  is  preferable  to  fracture  by  a  mechan- 
ical appliance  (osteoclasis). 

Genu  varum  (bow-legs)  is  the  opposite  of  knock-knee. 
Usually  both  legs  are  bowed  07it,  the  knees  being  widely 
separated,  the  tibise  and  femurs,  as  a  rule,  being  curved,  and 


ORTHOPEDIC  SURGERY. 


523 


Fig.  155. — Talipes 
equiiius   (Albert). 


Fig.  156. — Talipes 
calcaneus  (Albert). 


the  feet  being  turned  in.     This  disease  is  due  to  rickets,  the 
weight  of  the  body  producing  the  deformity  in  early  life. 
In    older    people    incurable 
bow-legs  may  arise  from  ar- 
thritis deformans. 

Treatment. — Some  mild 
cases  of  genu  varum  recover 
as  a  result  of  improvement  of 
the  health.  Ordinary  cases 
are  treated  by  braces,  by  plas- 
ter-of-Paris  bandages,  and 
by  attention  to  the  general 
health.  When  the  bones 
have  hardened  osteotomy 
is  indicated. 

Club-hand. — A  congenital  deformity  in  which  the  hand 
deviates  from  the  normal  relation  to  the  forearm.  It  is  usu- 
ally associated  with  other  deformities.  In  some  cases  the 
radius  and  possibly  some  of  the  carpal  bones  are  absent. 

Treatment. — By  massage  and  passive  motion,  by  immob- 
ilization, by  tenotomy  or  osteotomy. 

Talipes  (club-foot)  is  a  permanent  deviation  of  the  foot. 
There  are  several  forms.  Talipes  cqtdmis  (Fig.  155)  is  a  con- 
firmed extension;  talipes  calcaneus  (Fig.  156)  is  a  confirmed 
flexion  ;  talipes  variis  is  a  confirmed  adduction  and  inversion  ; 
and  talipes  valgus  is  a  confirmed  abduction  and  eversion.  Two 
of  these  forms  may  be  combined,  as  in  talipes  equino-varus 
(Fig.  157),  talipes  equino-valgus,  talipes  calcaneo-varus,  and 
talipes  calcaneo-valgus.  The  causes  of  talipes  are  con- 
genital or  acquired.  The  congenital  form  is  due  to  persist- 
ence of  the  fetal  form  of  the  foot.  Acquired  cases  may  arise 
from  infantile  paralysis, 
from  spastic  contrac- 
tions, from  cicatrices, 
from  traumatisms,  from 
arrest  of  bony  growth 
following  upon  bone 
inflammation,  or  from 
hysterical    contractures. 

Talipes      egjtinus      is 
rarely   congenital, 
this    condition    the 
tient    walks    upon 


In 

pa- 
the 


Fig. 


157. — Double  equino-varus  (Am.  Text-book 
oy  Surgery). 


toes  and  cannot  bring  the  heel  to  the  ground. 

Talipes  Calcaneus. — The  patient  walks  upon  the  heel  and 


524  MODERN  SURGERY. 

cannot  bring  the  toes  to  the  ground.  The  true  form  is 
seen  in  congenital  cases,  the  flexors  of  the  foot  being  short- 
ened, and  the  tendo  AchilHs  being  lengthened. 

Talipes  varus  is  rarely  met  with  without  equinus.  In  this 
condition  the  patient  walks  on  the  outer  edge  of  the  foot. 

Talipes  valgus  is  met  with  in  flat-foot.  The  patient  walks 
on  the  inner  edge  of  the  foot. 

Talipes  eqiiino-varus. — The  heel  is  raised  and  the  patient 
walks  upon  the  outer  edge  of  the  foot.  This  is  the  usual 
congenital  form. 

Talipes  equino-valgus  is  very  rarely  congenital.  The  heel  is 
raised  and  the  patient  walks  upon  the  inner  side  of  the  foot. 

Talipes  calcaneo-variis  is  a  combination  of  calcaneus  and 
varus. 

Talipes  calcaneo-valgus  is  a  combination  of  calcaneus  and 
valgus. 

Treatment. — In  congenital  cases  the  condition  is  usually 
manifest  on  both  sides,  and  is  nearly  always  talipes  equino- 
varus.  Congenital  club-foot  should  be  treated  in  infancy,  and 
when  a  restoration  to  position  can  be  effected  by  the  hands 
of  the  surgeon,  is  treated  by  plaster-of-Paris  bandages.  If  a 
child  has  begun  to  walk,  it  may  still  be  possible  to  correct  the 
deformity  eventually  by  manipulations,  by  plaster-of-Paris 
bandages,  or  by  club-foot  shoes,  but  most  cases  require  tenot- 
omy of  the  tendo  Achillis  before  the  application  of  the  shoe 
or  the  plaster.  The  club-foot  shoe  may  do  good  service,  but  in 
many  instances  it  is  painful  and  is  not  so  efficient  as  plaster. 
In  severe  cases,  before  applying  the  plaster,  the  patient  is 
given  ether ;  the  surgeon  cuts  the  tendo  Achillis,  the  ten- 
dons of  the  anterior  and  posterior  tibial  muscles,  and  the 
plantar  fascia,  and  forcibly  corrects  the  deformity.  In  old 
cases  with  alteration  in  the  shape  of  the  bones,  cuneiform 
osteotomy,  or  the  removal  of  the  cuboid  or  other  tarsal 
bones,  is  indicated.  In  these  cases  Phelps  advises  a  trans- 
verse incision  through  all  the  plantar  soft  parts.  In  talipes 
due  to  infantile  paralysis  the  operative  treatment  is  the  same, 
but  we  should  not  immobilize  in  plaster,  but  rather  in  some 
apparatus  which  can  easily  be  removed  to  permit  the  use  of 
massage  and  electricity.  In  some  cases  of  talipes  calcaneus 
the  surgeon  may  be  forced  to  shorten  the  tendo  Achillis. 
In  paralytic  cases  Nicoladoni's  operation  is  occasionally 
employed.  This  consists  in  dividing  the  tendon  of  the 
paralyzed  muscle  and  attaching  its  distal  end  to  the  adjacent 
tendon  of  a  healthy  muscle.  (For  full  consideration,  see  a 
work  on  Orthopedic  Surgery.) 


ORTHOPEDIC  SURGERY.  525 

Pes  planus  (flat-foot)  is  the  loss  of  the  arch  of  the  foot 
due  to  muscular  paralysis  or  ligamentous  weakness,  to  pro- 
longed standing,  or  to  trauma.  Many  cases  are  due  to 
rickets.  Spurious  flat-foot  or  inflammatory  flat-foot  occurs 
in  Pott's  fracture,  and  in  inflammation  of  the  ankle-joint  or 
the  tendon  of  the  peroneus  longus.  Static  flat-foot  is  due  to 
"  lack  of  balance  between  the  weight  of  the  body  and  the 
strength  of  the  foot"  (Moore).  All  children  are  born  with 
flat-feet,  but  the  arch  usually  begins  to  form  soon  after  birth, 
but  in  some  cases  it  never  forms.  This  condition  is  pro- 
ductive of  much  pain  on  standing.  Flat-foot 
can  at  once  be  recognized  by  wetting  the 
sole  of  the  patient's  foot  with  a  colored 
fluid  and  causing  him  to  step  firmly  upon  a 
piece  of  paper  (Fig.  158,  A,  b).  It  can  also 
be  detected  by  measurement  to  find  the  mid- 
dle of  the  foot.  In  flat-foot  the  extremity  is 
lengthened.  Flat-foot  causes  much  pain 
upon  walking ;  in  fact,  the  individual  may  =    «    ,   f 

^  ,  ,  .        ,      ,  Ti    •        •  •    1   1  v\G.  158. — Print  of  a 

be  completely  crippled.      rain  is   quickly     normal  '  foot-soie    (a) 

,.  ,  • , ,-  \  iirn-  „        and  of  a  flat   foot-sole 

relieved  upon  sitting  down.    Walking  upon     (b)  (Albert). 
the  toes  is  not  painful. 

Treatment. — In  static  flat-foot  exercise  is  practised  sev- 
eral hours  a  day  to  increase  the  arch.  Rising  upon  the  toes 
again  and  again  is  valuable.  After  exercise  the  patient  rests 
for  a  time,  sitting  tailor-fashion  with  legs  crossed  under  him. 
Massage  is  valuable.  A  shoe  should  be  made  containing  a 
piece  of  steel  so  arranged  as  to  raise  the  arch  of  the  foot. 
The  patient's  general  health  must  also  be  looked  to.  In 
very  severe  cases  operation  may  be  required.  Gleich 
shortens  the  foot  and  raises  the  arch  by  saw^ing  through  the 
OS  calcis  and  fastening  the  posterior  part  at  a  lower  level. 
Trendelenburg  advises  supramalleolar  osteotomy.  This 
operation  permits  us  to  adduct  the  foot  and  put  it  in  this 
position  in  plaster.  In  paralytic  flat-foot,  which  arises  from 
infantile  paralysis,  employ  exercise,  electricity,  and  massage. 

Pes  cavUS  (hollow-foot)  is  an  increase  in  the  arch  of 
the  foot,  due  to  contraction  of  the  peroneus  longus  muscle 
or  to  paralysis  of  the  muscles  of  the  calf  It  is  the  opposite 
of  flat-foot. 

Treatment. — A  shoe  is  worn  containing  a  plate  of  steel  in 
the  sole,  and  pressure  is  applied  over  the  instep.  Tenotomy, 
cutting  of  the  plantar  fascia,  or  excision  of  bone  may  be 
required. 

Hallux  valgus,  or  varus,  a  displacement  of  the  great 


526  MODERN  SURGERY. 

toe  outward  or  inward,  may  occur  in  the  young,  but  it  is 
most  frequent  in  old  men.  It  arises  oftener  from  wearing 
narrow  shoes,  but  may  be  due  to  gout,  or  to  rheumatic  gout. 
In  hallux  valgus  a  bunion  is  apt  to  form  over  the  metatarso- 
phalangeal joint. 

Treatment. — An  arrangement  may  be  worn  to  straighten 
the  toe  and  to  protect  the  bunion  (Fig.  148),  osteotomy  may 
be  performed  upon  the  metatarsal  bone,  the 
joint  may  be  excised,  or  amputation  may  be 
required. 

Hammer-toe  (Fig.  159)  is  the  flexion  of 

one  or  more  toes  at  the  first  interphalangeal 

^''"merll^?^"''      joint.     Shattuck  shows  that  this  condition  is 

due  to  contraction  of  "  the  plantar  fibers  of 

the  lateral  ligaments  of  the  joint."  ^     This   disease  usually 

begins  in  youth.     A  bunion  is  apt  to  form,  and  the  joint  may 

be  dislocated. 

The  treatment  is  excision  of  the  joint  or  amputation. 
Terrier's  plan  consists  in  making  a  dorsal  flap,  removing  a 
bursa  if  one  is  found,  dividing  the  extensor  tendon,  opening 
the  articulation,  removing  each  articular  surface  with  cutting- 
forceps,  suturing  the  soft  parts,  and  applying  a  plantar  spHnt 
for  two  weeks.^ 

Metatarsalgia  (Morton's  Disease). — A  painful  con- 
dition of  the  foot,  due  to  jamming  of  a  nerve  between  the 
heads  of  the  fourth  and  fifth  metatarsal  bones.  It  is  usually 
associated  with  flat-foot. 

Treatment. — Mild  cases  may  be  cured  occasionally  by 
wearing  well-fitting  shoes  and  employing  massage.  Some 
cases  require  a  brace.  Severe  cases  demand  resection  of  the 
fourth  metatarsophalangeal  joint,  or  amputation  of  the  fourth 
toe,  and  with  it  the  head  of  the  fourth  metatarsal  bone. 

Coxa  vara  is  bending  of  the  neck  of  the  femur,  the  hip- 
joint  being  perfectly  healthy,  and  the  condition,  as  a  rule, 
being  unilateral.  This  condition  was  described  by  Miiller  in 
1889.  The  disease  arises,  as  a  rule,  between  the  thirteenth 
and  twentieth  years,  and  the  commonly  accepted  view  has 
been  that  the  deformity  is  rachitic,  but  Kredel  has  recently 
reported  two  congenital  cases.^  The  patient  develops  a  limp, 
and  grows  tired  after  slight  exertion,  but  there  is  no  swelling 
or  tenderness,  and  little  or  no  pain.  Shortening  after  a  time 
becomes  apparent,  and  the  trochanter  can  be  detected  above 
Nelaton's  line.     The  extremity  is  adducted. 

1  American  Text-book  of  Surgery.         "  Revue  de  Chirurgie,   July,  1S95. 
3  Centralbl.f.   Chir.,  Oct.  17,  1896. 


DISEASES  AND   INJURIES   OF  NERVES.  527 

Treatment. — As  long  as  bending  is  progressing  employ- 
rest.  When  the  bone  hardens  perform  osteotomy  below  the 
trochanters. 

Flail-joints. — After  an  attack  of  infantile  paralysis  in 
which  the  entire  lower  extremity  of  each  side  was  involved, 
the  limbs  are  limp  and  swing  flail-like  when  the  extremity  is 
made  to  move,  and  the  joints  are  much  relaxed.  In  such 
cases  the  psoas  and  iliacus  muscles  are  never  completely 
paralyzed,  and  the  aim  of  the  surgeon  is  to  utilize  these 
muscles  in  enabling  the  patient  to  walk.  In  many  cases  the 
application  of  apparatus  is  sufficient.  In  others  ankylosis  is 
established  by  operation  in  the  ankles  and  knees,  so  as  to 
give  the  psoas  and  iliacus  control  of  the  legs. 

XXII.  DISEASES  AND  INJURIES  OF  NERVES. 

I.  Diseases  of  Nerves. 

Neuritis,  or  inflammation  of  a  nerve,  may  be  limited 
or  be  widely  distributed  (multiple  neuritis).  The  first-men- 
tioned form  will  here  be  considered.  The  causes  of  neuritis 
are  traumatism,  wounds,  over-action  of  muscles,  gout,  rheu- 
matism, syphilis,  fevers,  and  alcohoHsm. 

Syraptoms. — The  symptoms  of  neuritis  are  as  follows: 
excessive  pain,  usually  intermittent,  in  the  area  of  nerve- 
distribution.  The  pain  is  worse  at  night,  is  aggravated  by 
motion  and  pressure,  and  occasionally  diffuses  to  adjacent 
nerve-areas  or  awakens  sympathetic  pains  in  the  opposite 
side  of  the  body.  The  nerve  is  very  tender.  The  area  of 
nerve-distribution  feels  numb  and  is  often  swollen.  Early 
in  the  case  the  skin  is  hyperesthetic ;  later  it  may  become 
anesthetic.  The  muscles  atrophy  and  present  the  reactions 
of  degeneration ;  that  is,  the  muscles  first  cease  to  respond 
to  rapidly-interrupted,  and  next  to  s/ozu/j'-'mterrupted,  faradic 
currents ;  faradic  excitability  diminishes,  but  galvanic  excita- 
bility increases.  When,  in  neuritis,  faradism  produces  no 
contraction,  a  slowly-interrupted  galvanic  current  which  is 
so  weak  that  it  would  produce  no  movement  in  the  healthy 
muscles  causes  marked  response  in  the  degenerated  muscles. 
In  health  the  most  vigorous  contraction  is  obtained  by  clos- 
ing with  the  —  pole ;  in  degenerated  muscles  the  most 
vigorous  contraction  is  obtained  by  closmg  with  the  -f  pole. 
When  voluntary  power  returns  galvanic  excitability  declines, 
but  power  is  often  nearly  restored  before  faradic  excitability 
becomes  manifest  (Buzzard). 

Treatment. — The  treatment  of  neuritis  consists  of  rest 


528  MODERN  SURGERY. 

upon  splints,  ice-bags  early  in  the  case,  and  hot-water  bags 
later.  Blisters  are  of  value  in  traumatic  neuritis.  Massage 
and  electricity  must  be  used  to  antagonize  degeneration. 
Deep  injections  of  chloroform  may  allay  pain.  Treat  the 
patient's  general  health,  especially  any  constitutional  disease 
or  causative  diathesis.  The  salicylate  of  ammonium  or 
phenacetin  may  be  given  internally.  In  some  cases  nerve- 
stretching  is  advisable. 

Neuralgia  is  manifested  by  violent  paroxysmal  pain  in 
the  trajectory  of  a  nerve.  This  disease  belongs  chiefly  to 
the  physician,  except  in  very  bad  cases.  Neuralgia  of  stumps 
and  scars  belongs  to  the  surgeon,  and  is  due  to  neuromata, 
or  entanglement  of  nerve-filaments  in  a  cicatrix.  Tic 
douloureux  and  other  intractable  neuralgias  require  careful 
removal  of  any  cause  of  reflex  irritation  (stomach,  eyes, 
uterus,  nose,  throat,  etc.).  Tic  douloureux  has  been  treated 
by  removal  of  the  Gasserian  ganglion  (page  533);  removal 
of  Meckel's  ganglion  ;  ligation  of  the  common  carotid  artery ; 
neurectomy  of  terminal  branches  (page  532);  division  of 
motor  nerves ;  massive  doses  of  strychnin  (Dana)  and 
purgatives  (Esmarch). 

Treatment  of  Neuralg-ia  of  Stumps. — Excise  the  scar; 
find  the  bulbous  end  of  the  nerve  and  cut  it  off.  Senn  tells 
us  to  section  the  nerve  by  V-shaped  cuts,  the  apex  of  the  V 
being  toward  the  body,  and  to  suture  the  flaps  together. 
Senn's  method  will  prevent  recurrence.  In  some  cases  re- 
amputation  is  performed.  In  entanglement  of  a  nerve  in 
a  scar  remove  a  portion  of  a  nerve  above  the  scar. 

2.  Wounds  and  Injuries  of  Nerves. 

Section  of  Nerves  (as  from  an  incised  wound). — In 
nerve-section  the  entire  peripheral  portion  of  the  nerve  de- 
generates and  ceases  structurally  to  be  a  nerve  in  a  few 
weeks,  but  after  many  months,  or  even  after  years,  the  nerve 
again  regenerates — with  difficulty,  if  union  of  the  ends  has 
not  taken  place,  with  much  greater  ease  if  the  ends  have 
united.  The  proximal  end  only  suffers  in  the  portion  im- 
mediately adjacent  to  the  section  ;  it  degenerates,  but  rapidly 
regenerates,  and  a  bulb  or  enlargement  composed  of  fibrous 
tissue  and  small  nerve-fibers  forms  just  above  the  line  of 
section  ;  this  bulb  adheres  to  the  perineural  tissues.  Union 
of  a  divided  nerve  is  brought  about  by  the  projection  of  an 
axis-cylinder  from  the  proximal  end  or  from  each  end  and 
the  fusion  of  these  cylinders.  The  nearer  the  two  ends  are  to 
each  other  the  better  is  the  chance  of  union. 


DISEASES  AND   INJURIES   OF  NERVES.  529 

Symptoms. — Pronounced  changes  occur  in  the  trajectory 
of  a  divided  nerve.  The  muscles  degenerate,  atrophy  and 
shorten,  and  show  the  reactions  of  degeneration.  When 
union  of  the  nerve  occurs  the  muscles  are  restored  to  a 
normal  condition.  If  the  nerve  contains  sensory  fibers,  com- 
plete anesthesia  (to  touch,  pain,  and  temperature)  usually 
follows  its  division  ;  but  if  a  part  is  supplied  by  another  nerve 
as  well  as  by  the  divided  one,  anesthesia  will  not  be  com- 
plete. Trophic  changes  arise  in  the  paralyzed  parts.  Among 
these  changes  are  muscular  atrophy  ;  glossy  skin  ;  cutaneous 
eruptions;  ulcers;  dry  gangrene;  painless  felons;  falling  of  the 
hair;  brittleness,  furrowing,  or  casting  off  of  the  nails;  joint- 
inflammations  ;  and  ankylosis.  Immediately  after  nerve-sec- 
tion vasomotor  paralysis  comes  on,  and  for  a  few  days  the 
paralyzed  part  presents  a  temperature  higher  than  normal. 
The  diagnosis  as  to  which  nerve  is  cut  depends  upon  a  study 
of  the  distribution  of  paralysis  and  anesthesia.^ 

Treatment. — In  all  recent  cases  of  nerve-section,  suture 
the  ends.  In  123  cases  of  primary  suture,  119  were  cured 
in  from  one  day  to  one  year  (Willard).  In  130  cases  of 
secondary  suture,  80  per  cent,  were  more  or  less  improved 
(Willard).  If  the  patient  is  not  seen  until  long  after  the 
accident,  incise  and  apply  sutures  (secondary  sutures) ;  if 
the  nerve  cannot  be  found,  extend  the  incision,  find  the 
trunk  above  and  trace  it  down,  and  find  the  trunk  below  and 
follow  it  up.  Even  after  primary  suture  loss  of  function  is 
bound  to  occur  for  a  time.  After  secondary  suture  sensation 
may  return  in  a  few  days,  but  it  may  not  return  until  after  a 
much  longer  period  ;  in  any  case  muscular  function  is  not 
restored  for  months.  In  partial  section  of  a  nerve  the  ends 
should  be  sutured.  In  secondary  suture  it  may  be  necessary 
to  perform  "  lengthening  "  in  order  to  approximate  the  ends. 

Pressure  upon  nerves  may  arise  from  callus,  scars, 
pressure  of  a  dislocated  bone  or  a  tumor,  or  pressure  from 
an  external  body.  The  symptoms  may  be  anesthetic,  para- 
lytic, and  trophic.  The  treatment  is  as  follows  :  remove  the 
cause  (reduce  a  dislocated  bone,  chisel  away  callus,  excise  a 
scar,  etc.) ;  then  employ  massage,  douches,  and  electricity. 

Dislocation  of  the  Ulnar  Nerve  at  the  Blbow. — 
This  condition  is  very  rare.  It  may  occur  as  a  complication 
of  a  fracture  or  a  dislocation,  or  as  an  uncomplicated  condi- 
tion. It  may  be  produced  by  violence  or  by  muscular  effort, 
which  ruptures  the  fascia  whose  function  is  to  retain  the 
nerve  back  of  the  inner  condyle  of  the  humerus.     In  some 

^  See  Bowlby  on  Injuries  of  N'erves. 
34 


530  MODERN  SURGERY. 

cases  the  symptoms  are  slight  and  transitory,  the  nerve  func- 
tionating well  in  its  new  situation.  As  a  rule,  there  are  pain, 
numbness,  or  anesthesia  of  the  ulnar  trajectory,  some  stiff- 
ness of  the  elbow  and  stiffness  of  the  little  finger  or  ring  finger. 
The  nerve  can  be  felt  in  front  of  the  inner  condyle  of  the  hu- 
merus.     In  some  cases  neuritis  follows,  with  trophic  changes. 

Treatment. — McCorniick's  Operation. — Expose  the  nerve 
by  an  incision,  incise  the  fibrous  tissue  back  of  the  inner 
condyle,  and  press  the  nerve  into  the  bed  prepared  for  it  and 
hold  it  in  place  by  sutures  of  kangaroo-tendon  passing 
through  the  triceps  tendon.  Wharton  advises  suturing  also 
"the  margin  of  the  fascial  expansion  of  the  triceps  tendon 
superficial  to  the  nerve."  ^ 

Contusion  of  Nerves. — The  symptoms  of  contusion  of 
nerves  may  be  identical  with  those  of  section.  Sensation  or 
motion,  or  both,  may  be  lost.  The  case  may  get  well  in  a 
short  time,  or  the  nerve  may  degenerate  as  after  section. 

The  treatment  at  first  is  rest,  and  later  electricity,  massage, 
frictions,  and  douches. 

Punctured  Wounds  of  Nerves. — The  symptoms  of 
punctured  wounds  of  nerves  may  be  partly  irritative  (hyper- 
esthesia, acute  pain,  and  muscular  spasm)  and  partly  paralytic 
(anesthesia,  muscular  wasting,  and  paralysis). 

The  treatment  is  the  same  as  that  for  contusion. 

3.  Operations  upon  Nerves. 

Neurorrhaphy,  or  Nerve-suture. — When  a  nerve  is 
completely  or  partially  divided  by  accident  it  should  be 
sutured.  The  instruments  required  are  an  Esmarch  ap- 
paratus, a  scalpel,  blunt  hooks,  dissecting-forceps,  hemo- 
static forceps,  curved  needles  or  sewing-needles,  a  needle- 
holder,  and  catgut  or  kangaroo-tendon.  In  primary  suture 
render  the  part  bloodless  and  aseptic.  Enlarge  the  incision 
if  necessary.  If  the  ends  can  readily  be  approximated,  pass 
two  or  three  sutures  through  both  the  nerve  and  its  sheath 

and  tie  them  (Fig.  160).  If  the  ends  can- 
_     not  be  approximated,  stretch  each  end 

and  then  suture.     Remove  the  Esmarch 

band,  arrest  bleeding,  suture  the  wound, 
Fig.  160.— Nefve-suture.       drcss  antiseptically,  and  put  the  part  in 

a  relaxed  position  on  a  splint.  After 
union  of  the  wound  remove  the  splint  and  use  massage, 

^  A  report  of  fourteen  cases  of  dislocation  of  the  ulnar  nerve  at  the  elbow, 
by  H.  R.  y<i  hzxion,  A ??z.  Jour.  Med.  Sciences,  Oct.,  1895. 


S 
« 


DISEASES  AND   INJURIES   OF  NERVES.  53 1 

frictions,  electricity,  and  the  douche.  The  operation  in  some 
instances  fails,  but  in  many  cases  succeeds.  In  some  few 
cases  sensation  returns  in  a  few  days,  but  in  most  cases  does 
not  return  for  many  weeks  or  months.  Sensation  is  restored 
before  motor  power.  Secondary  suture  is  performed  upon 
cases  long  after  division  of  a  nerve.  The  part  is  rendered 
aseptic  and  bloodless ;  an  incision  is  made ;  the  bulbous 
proximal  end  is  easily  found  and  loosened  from  its  adhesions; 
the  shrunken  distal  end  is  sought  for  and  loosened  up  (it  may 
be  necessary  to  expose  the  nerve  below  the  wound  and  trace 
its  trunk  upward) ;  the  entire  bulb  of  the  proximal  end  is 
cut  off;  about  one-quarter  of  an  inch  of  the  distal  end  is  re- 
moved (Keen) ;  each  end  is  stretched, 
and  the  ends  are  approximated  and  (f^^^^^"^"^ 

sewn    together.      If  even   stretching    *-      '        — ^  '       -' 

does  not  permit  of  approximation, 
adopt  one  of  Bowlby's  expedients 
(Fig.  161),  or  graft  a  bit  of  nerve 
from  a  recently  amputated  limb  or 

c  1  •  1   /-J.  1  j-r       Fig.  161. — Suture  of  a  nerve  by 

from  a  lower  animal  (it  makes  no  dii-       splitting  the  ends  (Beach). 
ference    as    to    whether    the    grafted 

nerve  were  motor,  sensory,  or  mixed).  Mayo  Robson  has 
succeeded  in  grafting  the  spinal  cord  of  a  rabbit  in  the 
median  nerve  of  a  man.  The  restoration  of  function  was 
complete.  Von  Bergmann  suggests  shortening  the  Hmb  by 
excising  a  piece  of  bone.  Letievant  has  attached  the  cut 
end  of  the  peripheral  portion  of  a  divided  nerve  to  an  adja- 
cent uncut  nerve.  Assaky  uses  the  suture  a  distance,  catgut 
passing  from  end  to  end  and  serving  as  a  bridge  for  repara- 
tive material. 

Neurectasy,  Neurotomy,  and  Neurectomy. — Neurec- 
tasy, or  nerve-stretching,  may  be  applied  to  motor,  sensory,  or 
mixed  nerves.  A  nerve  can  be  stretched  about  one-twentieth 
of  its  length  (Vogt).  Neurectasy  has  been  employed  for  neu- 
ralgia, neuritis,  muscular  spasm,  hyperesthesia,  anesthesia, 
painful  ulcer,  perforating  ulcer,  and  the  pains  of  locomotor 
ataxia.  The  operation,  which  was  once  the  fashion,  seems  to 
benefit  some  cases,  but  it  is  not  now  thought  so  highly  of  as 
formerly.  The  incision  for  neurectasy  is  identical  with  the 
incision  for  neurectomy  or  neurotomy  of  the  same  nerve. 
Neurotomy,  or  section  of  a  nerve,  is  only  performed  upon 
small  and  purely  sensory  nerves.  It  is  performed  chiefly  for 
peripheral  neuralgia  or  for  some  other  painful  malady.  It  is 
useless  because  sensation  soon  returns.  Paget  saw  return  of 
sensation  entirely  in  four  weeks  after  division  of  the  median 


532  MODERN  SURGERY. 

nerve.  Corning  endeavors  to  prevent  this  regeneration  by 
inserting  oil  between  the  ends.  He  uses  oil  of  theobroma 
containing  enough  paraffin  to  make  the  melting-point  105°. 
The  oil  is  melted,  is  injected  .around  the  nerve,  and  cold  is 
applied.  The  nerve  is  now  sectioned  with  a  canaliculated 
knife,  the  ends  are  separated  widely,  more  oil  is  injected,  and 
cold  is  again  appHed.  The  theory  is  that  this  oil,  which  is 
solid  at  the  temperature  of  the  body,  devitalizes  the  nerve  at 
the  point  of  section  and  acts  as  a  barrier  to  the  passage  of  re- 
generating fibers.  This  method  has  been  applied  especially  in 
cervicobrachial  neuralgia.^  Neiu'ectoniy,  or  excision  of  a  por- 
tion of  a  nerve-trunk,  is  only  applicable  to  sensory  nerves  and 
to  painful  affections. 

Stretching  of  the  Sciatic  Nerve. — Some  surgeons 
stretch  the  sciatic  nerve  by  anesthetizing  the  patient  and 
holding  the  leg  and  thigh  in  line,  strong  flexion  being  made 
upon  the  hip,  the  entire  lower  extremity  being  used  as  a 
lever  (Keen).  This  method,  which  has  caused  death,  inflicts 
needless  damage,  and  the  operative  plan  is  safer  and  better. 
The  instruments  required  are  a  scalpel,  hemostatic  forceps, 
dissecting-forceps,  an  Allis  dissector,  retractors,  and  a  scale 
with  a  handle  and  a  hook.  The  patient  lies  prone,  the 
thighs  and  legs  being  extended.  An  incision  four  inches  in 
length  is  made  a  little  external  to  the  middle  of  the  thigh, 
and  going  at  once  through  the  deep  fascia ;  the  biceps  is 
found  and  is  drawn  outward ;  the  nerve  is  discovered  between 
the  retracted  biceps  on  the  outside  and  the  semitendinosus  on 
the  inside,  resting  upon  the  adductor  magnus  muscle.  The 
nerve,  which  is  caught  up  by  the  finger,  is  first  pulled  down 
from  the  spine  and  then  up  from  the  periphery,  and  finally 
the  hook  of  the  scale  is  inserted  beneath  the  trunk  and  the 
nerve  is  stretched  to  the  extent  of  forty  pounds.  Very 
rarely  is  even  a  single  ligature  needed.  The  wound  is  sutured 
and  dressed.  If  the  incision  is  made  at  a  higher  level  below 
the  gluteo-femoral  crease,  the  sciatic  nerve  will  be  found  just 
by  the  outer  border  of  the  biceps. 

Neurectomy  of  the  Infraorbital  Nerve. — The  instru- 
ments required  in  this  operation  are  a  scalpel,  dissecting- 
forceps,  aneurysm-needle,  hemostatic  forceps,  blunt  hooks, 
an  Allis  dissector,  and  metal  retractors.  The  patient  lies 
upon  his  back,  the  head  being  a  little  raised  by  pillows.  The 
surgeon  stands  to  the  outside  of,  and  faces,  the  patient.  A 
curved  incision  one  and  a  half  inches  long  is  made  below 
the  lower  border  of  the   orbit.     The  nerve  lies  in  a  line 

1  Med.  Rec,  Dec.  5,  1896. 


DISEASES  AND  INJURIES   OF  NERVES.  533 

dropped  from  the  supraorbital  notch  to  between  the  two 
lower  bicuspid  teeth.  The  nerve  is  found  upon  the  levator 
labii  superioris  muscle,  and  a  piece  of  silk  is  passed  under 
the  nerve  by  an  aneurysm-needle  and  firmly  fastened.  The 
upper  border  of  the  incision  is  drawn  upward  ;  the  periosteum 
of  the  floor  of  the  orbit  is  elevated  and  held  by  a  retractor ; 
the  roof  of  the  infraorbital  canal  is  broken  through;  the  nerve 
is  picked  up  far  back  with  the  blunt  hook  and  is  divided  with 
scissors,  and  the  entire  nerve  is  drawn  out  by  making  traction 
upon  the  silk.  The  bleeding  in  the  orbit  is  checked  by  press- 
ure.    The  wound  is  stitched  without  drainage. 

Neurectomy  of  the  Supraorbital  Nerve. — In  this 
operation  shave  off  the  eyebrow.  The  instruments  required 
and  the  position  of  the  patient  are  as  for  the  operation  upon 
the  infraorbital  nerve.  A  curved  incision  one  inch  long  dis- 
closes the  nerve  as  it  emerges  from  the  supraorbital  notch 
or  foramen  at  the  junction  of  the  inner  and  middle  thirds  of 
the  eyebrow.  The  nerve  is  pulled  forward  and  cut  off  above 
and  below. 

Neurectomy  of  the  Inferior  Dental  Nerve. — The  in- 
struments are  the  same  as  for  any  other  neurectomy,  and  in 
addition  a  chisel,  a  mallet,  and  a  rongeur  forceps.  Make  a 
curved  incision  around  the  angle  of  the  jaw.  Lift  the  supra- 
ma.xillary  branch  of  the  facial  nerve  downward  (Kocher). 
Separate  the  masseter  muscle  with  a  periosteum-elev^ator  and 
slight  touches  with  the  knife.  Chisel  an  opening  in  the  center 
of  the  ascending  ramus  (Velpeau's  rule).  This  opening  ex- 
poses the  beginning  of  the  dental  canal  (Kocher).  If  neces- 
sary, the  opening  may  be  enlarged  with  a  rongeur.  Pull  the 
nerve  out  with  a  hook  and  remove  a  piece  from  it. 

Removal  of  the  Gasserian  Ganglion. — This  opera- 
tion is  dangerous,  bloody,  and  difficult,  and  is  only  under- 
taken in  very  severe  cases  of  tic  douloureux,  and  in  cases 
upon  which  less  grave  procedures  have  failed.  The  operation 
usually  cures  the  pain  if  the  patient  recovers  from  the 
actual  procedure.  The  mortality  is  from  12  to  15  per  cent. 
In  some  ca.ses  the  pain  has  subsequently  returned.  Out  of 
Keen's  9  cases  of  removal,  3  had  corneal  trouble,  but  in 
not  one  case  was  the  eye  lost.  Some  atrophy  is  apt  to  be 
noted  in  the  tongue,  and  the  eye  becomes  insensitive  and 
watery. 

Operation. — The  surgeon  is  provided  w^th  the  instruments 
for  osteoplastic  resection  of  the  skull.  Krause  and  others 
employ  a  surgical  engine.  Special  retractors,  various  hooks, 
scalpels,  a  dr>-  dissector,  dissecting-  and  hemostatic  forceps, 


534 


MODERN  SURGERY. 


and  an  electric  forehead-light  are  required.     Long  strips  of 

gauze  must  be  ready  for  packing 
in  case  of  hemorrhage.  The  pa- 
tient is  placed  recumbent,  with 
head  turned  to  the  opposite  side. 
A  large  osteoplastic  flap  is  formed 
in  front  of  the  ear  (Fig.  162),  and 
is  broken  down.  Hemorrhage  is 
arrested.  It  may  be  found  that 
the  meningeal  artery  has  been 
ruptured.  If  this  accident  has 
happened,  and  the  vessel  lies  in  a 
bony  canal,  plug  with  Horsley's 
wax.  If  the  vessel  is  bleeding 
upon  the  dura,  ligate  by  passing 
suture  ligatures  around  it.  If  it  is 
torn  off  at  the  foramen  spinosum, 
pack  with  iodoform  gauze,  and  postpone  the  rest  of  the  opera- 
tion for  forty-eight  hours.    It  may  be  necessary  at  any  stage 


Fig.  162. — Hartley's  osteoplastic 
flap  in  removal  of  Gasserian  ganglion 
(Tiffany). 


Fig.  163. — Removal  of  Gasserian  ganglion  (Krause)     A,  middle  meningeal  artery;  II, 
ophthalmic  division  :  iii,  submaxillary  division ;  o,  ganglion. 

of  this  formidable  operation  to  pack  the  wound  and  postpone 
completion  for  two  days.  The  next  step  is  to  lift  up  the  dura 
and  with  it  the  brain  (Fig.  163).     Find  the  inferior  maxillary 


DISEASES  AND   INJURIES   OF  THE  HEAD.  535 

nerve  and  clamp  it  with  hemostatic  forceps.  Find  the  supe- 
rior maxillary  nerve  and  clamp  it.  Loosen  the  nerves  from 
their  beds  with  a  dry  dissector.  Twist  the  clamp-forceps  so 
as  to  reel  up  the  nerves.  This  pulls  out  the  ganglion  intact 
with  the  motor  root  and  the  root  of  origin,  as  far  back  as 
the  pons  (Krause's  method).  Arrest  bleeding ;  close  the 
flap ;  sew  the  lids  of  the  affected  side  together ;  and  cover 
the  eye  with  a  watch-crystal. 

XXIII.    DISEASES   AND    INJURIES   OF  THE   HEAD. 

I.    Diseases  of  the  Head. 

In  approaching  cases  of  brain  disorder,  first  endeavor 
to  locate  the  seat  of  the  trouble ;  next,  ascertain  the 
nature  of  the  lesion  ;  and  finally,  determine  the  best  plan  of 
treatment,  operative  or  otherwise.  In  all  operations  upon 
the  brain  the  surgeon  must  be  able  to  determine  accurately 
the  situations  of  certain  fissures  and  convolutions,  the  find- 
ing of  the  situations  of  these  convolutions  and  fissures  com- 
prising the  science  of  craniocerebral  topography. 

TJic  regional  terms  used  in  craniocerebral  topography  are 
derived  from  Broca  (Fig.  165).    The  middle  meningeal  artery 


Fig.  164. — The  meningeal  artery  exposed  by  trephining  (after  Esmarch). 

is  found  at  the  pterion,  one  and  one-quarter  inches  posterior 
to  the  external  angular  process,  on  a  level  with  the  roof  of  the 
orbit  (Fig.  164).  The  fissures  and  convolutions  of  the  brain 
are  shown  in  Figs.  166,  167,  and  168.  The  fissure  of  Bichat 
is  marked  by  a  line  on  each  side  drawn  from  the  inion  to 
the  external  auditory  process.  A  line  from  the  glabella  to 
the  inion  overlies  the  median  fissure  and  the  superior  longi- 
tudinal sinus.     The  fissure  of  Rolando  is  very  important,  as 


536 


MODERN  SURGERY. 


marking  the  motor  region  of  the  brain.  It  begins  in  the 
median  Hne,  half  an  inch  posterior  to  the  middle  of  the  dis- 
tance between  the  inion  and  gla- 
bella (Keen).  This  fissure  runs 
downward  and  forward  at  an  angle 
of  67.5°  for  a  distance  of  three  and 
three-eighths  inches.  Chiene  finds 
the  fissure  of  Rolando  by  the  follow- 
ing method  :  he  takes  a  square  piece 


Fig.  165. — Skull  showing  the 
points  named  by  Broca:  As,  asterion 
(junction  of  the  occipital,  parietal, 
and  temporal  bones);  basion,  middle 
of  anterior  wall  of  foramen  magnum  ; 
B,  bregma  (junction  of  the  sagittal 
and  coronal  sutures);  G,  ophryon 
(on  a  level  with  the  superior  border 
of  the  eyebrows,  and  corresponding 
nearly  to  the  glabella,  the  smooth 
swelling  between  the  eyebrows)  ;  g, 
gonion  (angle  of  the  lower  jaw)  ;  /, 
inion  (external  occipital  protuber- 
ance) ;  L,  lambda  (junction  of  sagit- 
tal and  lambdoidal  sutures)  ;  N,  na- 
sion  (junction  of  the  nasal  and  front- 
al) ;  Ob,  obelion  (the  sagittal  suture 
between  the  parietal  foramina) ;  P, 
pterion  (point  of  junction  of  great 
wing  of  sphenoid  and  the  frontal, 
parietal,  and  squamous  bones.  This 
may  be  H-shaped  or  K-shaped,  or 
"  retourne,"  in  which  the  frontal  and 
temporal  just  touch) ;  S,  stephanion 
(or,  better,  the  superior  stephanion, 
intersection  of  ridge  for  temporal  fas- 
cia and  coronal  suture) ;  S' ,  inferior 
stephanion  (intersection  of  ridge  for 
temporal  muscle  and  coronal  suture). 


Fig.  166. — View  of  the  brain  from  above  (Ecker). 


of  paper  and  folds  it  into  a  triangle  (Fig.  1 70,  i) ;  the  angle  bag 
of  this  triangle  is  45  ° ;  the  edge  d  a  is  folded  back  on  the  dotted 
line  ae;  the  angle  dae  equals  half  of  45°,  or  22.5°,  and  the 
angle  cae  equals  the  same  (Fig.  170,  2);  unfold  the  paper 
in  the  line  ca;  in  the  figure  thus  formed  b a 0  =  45°  and 
eac  =  22.5°;  e a b  =  67.5°,  which  is  the  angle  desired.  Place 
the  point  a  in  the  mid-line  of  the  head,  over  the  point  of  ori- 
gin of  the  Rolandic  fissure ;  the  side  a  b  is  laid  along  the 
middle  line  of  the  head,  and  the  line  A  e  corresponds  to 
the  fissure  of  Rolando.^  Fig.  169  shows  Chiene's  scheme 
for  locating  various  points  upon  the  brain.  Horsley  de- 
termines  the   situation   of  the   Rolandic   fissure  by  the  use 


^  At?ierican  Text-book  of  Surgery, 


DISEASES  AND   INJURIES   OF   THE  HEAD.  537 

of  his  metal  cyrtometer  (Fig.  171).  He  places  the  point 
marked  zero  over  the  inioglabellar  line  and  midway  be- 
tween the  inion  and  the  glabella.     To  find  the  fissure  of 


Fig.  167.— Outer  surface  of  the  left  hemisphere  of  the  brain  (Ecker). 

Sylvius  (Fig.  167,  5,  s' ,  s"^,  draw  a  line  from  the  exter- 
nal angular  process  to  the  occipital  protuberance.  The 
fissure  of  Sylvius  begins  on  this   line  one  and  one-eighth 


Fig.  16S.— Inner  surface  of  the  right  hemisphere  of  the  brain  (Ecker). 

inches  behind  the  external  angular  process ;  the  main 
branch  of  the  fissure  runs  toward  the  parietal  eminence; 
the  ascending  branch  of  the  fissure  corresponds  to  the 
squamoso-sphenoidal   suture,  and  continues  upward  in  the 


538 


MODERN  SURGERY. 


same  line  half  an  inch  above  the  suture.  The  precentral 
sulcus  (Fig.  167,  f)  Hmits  anteriorly  the  ascending  frontal 
convolution;    it    runs   parallel    with    and    just   behind   the 


Fig.  169.— Chiene's  lines  for  localizing  brain-areas:  M  D  c  A,  Rolandic  or  motor  area;  A, 
anterior  branch  of  middle  meningeal  and  bifurcation  of  fissure  of  Sylvius ;  A  c,  horizontal 
part  of  Sylvian  fissure;  the  highest  part  of  the  lateral  sinus  touches  Ps  at  r;  ma,  precentral 
sulcus  ;  I,  beginning  of  inferior  frontal  sulcus  ;  K,  beginning  of  superior  frontal  sulcus  ;  M  B  c 
contains  the  supramarginal  convolution ;  B,  angular  gyrus. 

coronal  suture,  and  a  finger's  breadth  in  front  of  the  fissure 
of  Rolando.  The  intraparietal  fissure  (Figs.  166,  167,  ip) 
limits  the  motor  region  posteriorly.  It  begins  opposite  the 
junction  of  the  lower  and  middle  thirds  of  the  fissure  of 


Fig.  170. — Chiene's  method  of  fixing  position  of  the  Rolandic  fissure  {Am.  Text-book  of 

Siirgery). 

Rolando,  passes  upward  in  a  line  parallel  with  the  longi- 
tudinal fissure  and  midway  between  the  Rolandic  fissure 
and  the  parietal  eminence,  passes  by  the  parieto-occipital  fis- 


DISEASES  AND   IXJURIES   OF  THE  HEAD. 


539 


sure,  and  downward  and  backward  into  the  occipital  lobe. 
The  motor  areas,  which  on  the  outer  surface  are  adjacent  to 
the   fissure  of  Rolando,  are   shown  in    Figs.    i66  and    167. 


^.  ..■'l.,.6|.,.S|.,.'H.,.»|.,.»|.,.<|.,°| 


.l'^,.|3.  l.l»,.l^,.l'.   ,.K.T^ 


Fig.  171. — Horsley's  cyrtometer. 

The  superior  longitudinal  sinus  is  overlaid  by  a  line  from 
the  inion  to  the  glabella.  The 
lateral  sinus  is  indicated  by  a 
line  running  from  the  occipital 
protuberance  horizontally  out- 
ward to  a  point  one  inch  pos- 
teriorly to  the  external  auditory 
meatus,  and  from  this  point  by  a 
second  line  dropped  to  the  mas- 
toid process.  The  suprameatal 
triangle  of  Macewen  is  bounded 
by  the  posterior  root  of  the  zy- 
goma, the  posterior  bony  wall 
of  the  auditory  meatus,  and  a 
line  joining  the  two.  The  mas- 
toid process  is  opened  through 
Macewen's  triangle  to  avoid  in- 
jury to  the  lateral  sinus.  Bark- 
er's point,  the  proper  spot  to 
apply  the  trephine  in  abscess  of 
the  temporosphenoidal  lobe,  is 
one  and  one-fourth  inches  above 
and  one  and  one-fourth  inches 
behind  the  middle  of  the  external 
auditory  meatus.  Fig.  172  shows 
clearly  the  main  points  of  craniocerebral  topography,  obtained 
by  methods  approved  by  many  scientists. 

Diseases  of  the  Scalp. — The  scalp  is  composed  of  skin, 
subcutaneous  fat,  and  the  occipitofrontalis  muscle  and  apo- 
neurosis.    The  scalp  is  liable  to  inflammation  from  various 


Fig.  172. — Head,  skull,  and  cere- 
bral fissures  :  B  corresponds  to  Broca's 
convolution  ;  EAP,  external  angular 
process  ;  FR,  fissure  of  Rolando  ;  IF, 
inferior  frontal  sulcus  ;  IPF,  intrapari- 
etal  sulcus  :  MMA,  middle  meningeal 
artery;  OPr,  occipital  protuberance; 
PE,  parietal  eminence  :  POF,  parieto- 
occipital fissure  ;  SF,  Sylvian  fissure; 
A,  its  ascending  limb  ;  TS,  tip  of  tem- 
porosphenoidal lobe.  The  pterion  (to 
the  left  of  B)  is  the  region  where  three 
sutures  meet,  viz.,  those  bounding  the 
great  wing  of  the  sphenoid  where  it 
joins  the  frontal,  parietal,  and  tem- 
poral bones  (adapted  from  Marshall 
by  Hare). 


540  MODERN  SURGERY. 

causes,  and  also  to  other  diseases — namely,  tumors,  cysts, 
warts,  moles  (local  cutaneous  hypertrophies),  cirsoid  aneur- 
ysm (page  256),  nevi,  and  lupus.  Abscesses  of  the  scalp  are 
common.  If  an  abscess  forms  beneath  the  pericranium,  the 
pus  diffuses  over  the  area  of  one  bone,  being  limited  by 
the  attachment  of  the  pericranium  in  the  sutures.  If  an 
abscess  forms  in  the  tissue  between  the  occipitofrontaHs 
and  the  pericranium,  it  is  widely  diffused.  Treves  calls  this 
subaponeurotic  connective  tissue  "  the  dangerous  area." 
Abscess  of  the  subcutaneous  tissue  is  apt  to  be  limited 
because  of  the  great  amount  of  fibrous  tissue.  Abscess  is 
treated  by  instant  incision  at  the  most  dependent  part,  anti- 
septic irrigation,  and  drainage.  ■ 

Diseases  and  Malformations  of  the  Bones  of  the 
Skull. — The  bones  of  the  skull  are  liable  to  caries,  necrosis, 
osteitis,  periostitis,  atrophy,  hypertrophy,  tumors,  etc.  (see 
Diseases  of  Bones). 

MicrocephaltlS. — By  microcephalus  is  meant  unnatural 
smallness  of  the  head  due  to  imperfect  development.  Marked 
microcephalus  is  not  a  common  condition,  but  it  is  an  occa- 
sional cause  or  associate  of  idiocy.  A  child  may  be  born 
with  a  skull  completely  ossified  even  at  the  fontanelles,  or 
the  ossification  may  become  complete  soon  after  birth,  but 
in  many  cases  of  microcephalus  ossification  takes  place  late 
or  not  at  all.  In  microcephalus  the  face  is  apt  to  be  fairly 
well  developed  ;  the  jaws  are  prominent ;  the  forehead  is  flat ; 
the  cranium  and  brain  are  small ;  the  convolutions  of  the 
brain  are  simpler  than  is  natural ;  there  is  apt  to  be  marked 
asymmetry  of  the  two  sides  of  the  brain ;  internal  hydro- 
cephalus may  exist ;  areas  of  sclerosis  and  atrophy  are 
common  ;  porencephaly  is  not  unusual.  Some  patients  have 
perfect  motor  power ;  others  are  slow  and  inco-ordinate. 
Epilepsy,  chorea,  and  athetosis  frequently  complicate  the 
case.  Idiots  of  this  type  often  present  deformities  such  as 
cleft-palate,  strabismus,  distorted  ears,  hypertrophied  tongue, 
deformed  genitals  or  extremities,  ill-shaped  and  irregularly 
developed  teeth.  They  exhibit  irregular  muscular  move- 
ments, are  frequently  paralyzed  in  childhood  (infantile  para- 
plegia or  hemiplegia),  and  suffer  from  subsequent  contract- 
ures. These  idiots  are  active,  destructive,  excitable,  and 
are  liable  to  be  violent  and  almost  demoniacal.  Clouston 
says  they  look  impish  and  unearthly. 

Treatment. — Skilled  training  in  a  school  for  the  feeble- 
minded or  in  an  institution  for  idiots  is  necessary  in  treating 
microcephalus.     Idiots   have  but  little  power  of  attention, 


DISEASES  AND   INJURIES   OF   THE   HEAD.  54 1 

and  sensory  impressions  give  rise  to  but  few  concepts,  and 
these  are  feeble  and  fleeting.  In  order  to  educate  the  idiot 
it  is  highly  desirable  that  speech  be  acquired,  and  "  the  more 
strongly  the  attention  can  be  aroused  the  more  perfect  does 
speech  become  "  (Kirchhoff ).  The  principle  of  the  educa- 
tion of  idiots  is  to  stimulate,  co-ordinate,  and  guide  sight, 
hearing,  and  feeling. 

Lannelongue  of  Paris  has  suggested  an  operation  in  cases 
of  idiocy  with  premature  ossification  (see  Linear  Craniotomy, 
page  577).  In  this  procedure  the  author  has  no  confidence. 
Idiocy  is  a  general  disorder  and  not  a  local  brain  disease. 
Soft  parts  mould  bone,  and  bone  does  not  mould  soft  parts. 
There  is  no  evidence  that  the  brain  is  being  compressed ;  in 
fact,  the  simplicity  of  the  convolutions  suggests  the  contrary. 
In  many  typical  cases  of  microcephalic  idiocy  there  is  no 
synostosis  even  years  after  birth.  The  operation  has  been 
much  abused.  It  is  sometimes  fatal,  and,  although  a  fatality 
may  gratify  the  family,  a  surgeon  is  not  a  legal  executioner. 
The  remarkable  improvement  which  has  been  reported  in 
some  cases  results  probably  from  misconception  ;  the  new 
surroundings,  the  strange  faces,  the  firm  discipline,  the  effect 
of  the  anesthetic,  and  the  shock  of  the  operation  attract  the 
feeble  attention  and  rouse  the  sluggish  senses.  Many  cases 
are  brought  for  operation  because  they  are  for  the  time 
being  unusually  intractable  and  excitable,  and  the  return 
to  the  usual  level  of  conduct  after  operation  is  regarded 
as  a  permanent  gain  when  it  is  often  but  a  temporary  alle- 
viation. We  believe  that  scientific  training  is  the  proper 
treatment,  and  that  the  efficiency  of  training  is  not  in- 
creased by  the  previous  performance  of  craniotomy,  and 
we  follow  the  precept  of  Agnew,  that  a  surgeon  might 
as  well  cut  a  piece  out  of  a  turtle's  back  to  make  a  turtle 
grow^  as  to  cut  a  piece  out  of  the  skull  to  make  the  brain 
grow. 

Diseases  and  Malformations  Involving  the  Brain. 
— Meningocele  is  a  congenital  protrusion  of  the  cerebral 
membranes  through  a  bony  aperture,  the  sac  containing 
some  extracerebral  fluid.  Meningocele  feels  and  looks  like 
a  cyst  (is  translucent  and  fluctuates) ;  it  does  not  usually 
pulsate,  it  has  a  small  base,  it  becomes  tense  on  forcible 
expiration,  and  it  may  be  reduced. 

Encephalocele  is  a  congenital  protrusion  not  only  of 
membranes,  but  also  of  a  portion  of  the  brain  as  well,  the 
sac  containing  some  extracerebral  fluid.  Encephalocele  is 
small,  opaque,  does  not  fluctuate,  has  a  broad  base,  does 


542  MODERN  SURGERY. 

pulsate,  becomes  tense  on  forced  expiration,  and  attempts 
at  reduction  cause  pressure-symptoms. 

Hydrencephalocele  is  a  congenital  protrusion  of  mem- 
branes and  brain-substance,  the  interior  of  the  mass  com- 
municating with  the  ventricles  and  containing  ventricular 
fluid.  This  is  the  most  frequent  and  the  most  dangerous 
form.  Hydrencephalocele  is  larger  than  a  meningocele,  is 
translucent,  fluctuates,  rarely  pulsates,  is  pedunculated,  is 
rendered  a  little  tense  on  forced  expiration,  and  cannot  be 
reduced.^ 

Treatment. — For  hydrencephalocele  nothing  can  be  done, 
and  early  death  is  inevitable.  In  rare  instances  an  enceph- 
alocele  is  converted  into  a  meningocele,  and  the  bony 
aperture  closes,  thus  bringing  about  a  cure.  Among  the 
expedients  for  treating  meningocele  and  encephalocele  are 
electrolysis,  injection  of  Morton's  fluid  (gr.  x  of  iodin, 
gr.  XXX  of  iodid  of  potassium,  ,?j  of  glycerin),  pressure  and 
excision.  In  cases  of  meningocele,  when  portions  of  the  nerve- 
centers  are  not  contained  in  the  sac,  Mayo  Robson  advises  the 
performance  of  a  plastic  operation.  He  ligates  the  neck  of 
the  sac,  cuts  away  the  sac,  sutures  the  skin-flaps  separately, 
and  leaves  the  stump  outside  the  line  of  superficial  sutures. 
It  is  usually  possible  to  tell  by  palpation  if  nerve-centers  are 
in  the  sac,  but  if  in  doubt,  make  an  exploratory  incision,  and 
sweep  the  finger  around  inside  of  the  sac.^ 

Hydrocephalus. — In  external  hydrocephalus  the  fluid  is 
between  the  membranes  and  the  brain ;  in  internal  hydro- 
cephalus the  fluid  is  in  the  ventricles.  Hydrocephalus  may 
be  acute  or  chronic,  congenital  or  acquired. 

Acute  hydrocephalus,  which  results  from  meningitis 
(particularly  tubercular  meningitis),  is  usually  internal,  but 
may  be  external.  The  symptoms  are  headache,  elevated 
temperature,  delirium,  stupor,  convulsions,  paralysis,  and 
choked  disk. 

Treatment  of  acute  hydrocephalus  is  of  no  avail.  Tapping 
of  the  ventricles  may  be  tried. 

Chronic  hydrocephalus  is  usually  congenital.  The  cra- 
nium enlarges  enormously  and  the  bones  of  the  skull  are 
widely  separated.  The  broad  forehead  overhangs  the  eyes. 
The  child  is  an  idiot,  and  very  often  does  not  learn  to  walk 
or  to  talk.  Convulsions  and  palsies  are  common,  and  blind- 
ness is  frequent.     Such  children  usually  die  young. 

The  treatme7it  of  chronic  hydrocephalus  is  rarely  of  much 

1  Ai?ierican  Text-book  of  Surgery. 

^  Atn.Jour.  Aled.  Sciences,  Sept.,  1895. 


DISEASES  AND   INJURIES   OF  THE   HEAD.  543 

avail.  Pressure  by  strapping  with  adhesive  plaster  has  been 
tried.  Tappings  through  a  fontanelle  may  be  performed  by 
means  of  a  trocar  (only  sij  or  5iij  of  fluid  being  drawn  at  a 
time).  If  much  fluid  is  drawn,  the  head  must  be  strapped 
afterward.  If  the  skull  ossifies,  the  lateral  ventricles  may  be 
tapped.  It  has  been  proposed  to  drain  by  tapping  the  theca 
of  the  spinal  cord  (Quincke).  This  last  operation  is  called 
lumbar  puncture  (page  595). 

2.  Injuries  of  the  Head. 

Cephalhematoma  (caput  succedaneum),  which  is  a  col- 
lection of  bloody  serum  under  the  scalp  of  a  new-born 
child,  results  from  the  pressure  of  labor.  No  treatment  is 
required. 

Scalp-wounds  are  treated  as  are  other  wounds.  Even  a 
large  piece  of  scalp  with  only  a  narrow  pedicle  may  not 
slough ;  hence  try  to  save  any  piece  that  has  an  attachment. 
Always  shave  a  wide  area  and  disinfect  the  wound  thor- 
oughly. Stitch  the  wound  with  silkworm-gut.  The  hem- 
orrhage can,  in  most  instances,  be  controlled  by  the  sutures 
which  are  used  to  close  the  wound.  If  drainage  is  required, 
use  a  few  strands  of  silkworm-gut. 

Contusions  of  the  Head. — Scalp-swelling  from  hemor- 
rhage is  usually  considerable.  The  patient  may  be  stunned 
or  dazed.  The  swelling  of  hematoma  must  not  be  mistaken 
for  fracture  with  depression.  In  hematoma  there  is  a  cen- 
tral depression,  hard  pressure  on  the  centre  finds  bone  on  a 
level  with  the  general  contour  of  the  bone,  and  the  margin 
of  a  hematoma  is  circular,  is  not  quite  hard,  and  is  elevated 
above  the  general  contour.  In  depressed  fracture  the  edge 
is  on  a  level  with  or  below  the  level  of  the  general  bony  con- 
tour, and  the  margin  is  sharp  and  irregular.  The  treatment 
is  by  means  of  pressure  and  the  use  of  lead-water  and  laud- 
anum.    If  suppuration  arises,  at  once  incise. 

Concussion  or  I/aceration  of  the  Brain. — For  many 
years  it  has  been  customary  to  regard  concussion  as  a  con- 
dition produced  by  molecular  vibrations  in  the  nervous  sub- 
stance of  the  brain.  Buret's  classical  observations  have  pro- 
foundly modified  surgical  thought,  and  have  led  to  the 
opinion  that  in  concussion  of  the  brain  there  is  injury  to  the 
brain  itself,  a  rupture  of  cerebral  vessels  brought  about  by 
the  advance  and  recession  of  a  wave  of  cerebrospinal  fluid. 
This  wave  first  flows  in  the  direction  of  the  force.  Keen 
says    that   there    may   be   slight    brain-injuries   which    can 


544  MODERN  SURGERY. 

properly  be  called  "  concussions,"  but  it  is  better  to  consider 
concussion  as  synonymous  with  laceration  of  the  brain.  It 
seems,  however,  highly  improbable  that  slight  cases  of  con- 
cussion are  accompanied  by  vascular  rupture  or  organic 
mischief,  the  symptoms  are  too  transitory,  and  reaction  too 
rapid  and  complete  to  permit  of  any  such  view.  These 
slight  cases  are  identical  with  and  at  least  can  not  be  dis- 
tinguished from  shock.  The  cause  of  concussion  is  violent 
force,  either  direct  (as  a  blow  upon  the  head)  or  indirect  (as 
a  fall  upon  the  buttocks).  This  force  shakes,  oscillates,  or 
jars  the  brain,  giving  rise  to  waves  of  cerebrospinal  fluid, 
which  sometimes  rupture  vascular  twigs,  large  vessels,  or 
even  the  membranes.  In  the  slighter  ruptures  concussion 
only  exists ;  in  the  severe  ruptures  compression  soon  arises. 
Symptoras. — In  a  slight  case  of  brain-concussion  the 
patient  may  or  may  not  fall ;  his  face  is  pale ;  he  feels  weak, 
giddy,  nauseated,  and  confused ;  he  often  vomits,  but  soon 
reacts.  In  a  severe  case  he  lies  with  complete  muscular  relax- 
ation, cold  extremities,  pale  and  cold  skin,  shallow  and  quiet 
respiration,  frequent,  small,  soft,  and  irregular  pulse  (pulse 
may  not  be  detectable),  and  fluttering  heart.  He  seems 
unconscious,  but  can  usually  be  roused  to  monosyllabic 
response  by  shouting,  pinching,  or  holding  a  bright  light 
near  his  face.  Occasionally,  however,  there  is  complete  un- 
consciousness. The  urine  and  feces  are  often  passed  in- 
voluntarily. The  pupils  may  be  unaltered,  may  be  dilated  or 
contracted,  or  may  be  equal  or  unequal,  but  in  any  case  they 
will  react  to  light.  Paralysis  rarely  exists,  but  if  there  is 
paralysis  it  is  temporary.  The  temperature  at  first  is  sub- 
normal. In  a  severe  cortical  laceration  there  will  be  twitch- 
ings  or  even  general  convulsions,  or  the  patient  will  lie  curled 
up  with  limbs  flexed  and  eyelids  shut,  and  will  resist  all 
attempts  to  open  his  eyes  or  mouth  or  to  move  his  limbs  (A. 
Pearce  Gould).  Erichsen  called  this  condition  "  cerebral 
irritability."  As  the  patient  reacts  he  will  most  probably 
vomit.  Within  twenty-four  hours  he  usually  improves, 
but  is  feverish  and  complains  of  headache  and  lassitude, 
sometimes  becomes  delirious,  and  in  rare  cases  develops 
mania.  After  concussion  recovery  may  be  complete,  but, 
on  the  contrary,  a  person's  whole  nature  may  change :  he 
may  develop  hysteria,  insanity,  or  epilepsy,  and  in  many 
cases  there  is  complaint  for  a  long  time  of  headache,  insom- 
nia, low  spirits,  and  lassitude.  If  the  patient  in  concussion 
recedes  from,  instead  of  advancing  toward,  recovery,  coma 
will  set  in  or  inflammation  will  develop.     Keen  states  that 


DISEASES  AND   INJURIES   OF  THE  HEAD.  545 

the  prognosis  is  always  uncertain.  Any  concussion  pro- 
ducing unconsciousness  is  a  serious  injury,  because  consider- 
able laceration  has  probably  occurred. 

Treatment. — In  treating  brain-concussion,  bring  about 
reaction  by  the  administration  of  aromatic  spirits  of  ammo- 
nia (no  alcohol,  as  this  agent  excites  the  brain),  by  pouring 
a  few  drops  of  ammonia  on  a  handkerchief  and  holding  it 
near  the  nose,  by  surrounding  the  patient  (who  lies  in  bed 
with  a  pillow)  with  hot  bottles,  by  hot  irrigation  of  the  head, 
by  the  application  of  mustard  over  the  heart,  and  by  the 
administration  of  hot  coffee  or  hot  saline  enemata.  Do  not 
pour  fluid  into  the  patient's  mouth  until  he  becomes  able  to 
swallow.  If  he  cannot  swallow,  rely  on  hot  enemata  and 
hypodermatic  injections  of  strychnin.  Place  the  patient  in 
bed  in  a  quiet  room,  and  watch  him.  If  reaction  is  inordinate, 
apply  cold  to  the  head,  give  arterial  sedatives  and  diuretics, 
and  purge.  For  some  days  or  for  some  weeks,  according  to 
the  case,  insist  on  an  easy  life.  Give  a  plain  diet  containing 
a  minimum  of  meat,  administer  an  occasional  purgative,  and 
secure  sleep.  Sleep  can  often  be  obtained  by  some  simple 
expedient,  such  as  the  administration  of  warm  milk,  placing 
a  hot-water  bag  to  the  abdomen  or  feet,  or  applying  a  mus- 
tard plaster  for  a  short  time  to  the  back  of  the  neck.  Irk 
cases  where  obstinate  wakefulness  exists,  it  becomes  neces- 
sary to  give  bromid,  chloral,  sulphonal,  trional,  or  some 
other  hypnotic.  Morphin  is  avoided  because  it  is  thought 
to  increase  venous  congestion  of  the  brain,  but  the  elder 
Gross  often  used  it,  especially  in  cerebral  irritation.  If  signs 
of  compression  arise,  it  is  best  to  trephine,  as  the  compressing 
agent  may  be  a  clot  (see  page  548).  If  inflammation  arises, 
some  surgeons  will  not  trephine ;  but  it  is  wise  and  proper, 
especially  if  the  damage  seems  to  be  localized,  to  incise  the 
scalp  and  inspect  the  bone.  If  a  fracture  is  discovered 
and  the  symptoms  are  serious,  perform  an  exploratory  tre- 
phining, open  the  dura,  and  secure  drainage  for  inflammatory 
products. 

In  any  severe  contusion  the  surgeon  should  at  once 
incise  the  scalp  and  inspect  the  bone.  For  many  weeks 
after  a  grave  concussion  a  patient  must  be  kept  away 
from  business  and  be  watched  because  of  the  possibility 
of  an  abscess  of  the  brain  arising,  and  because  of  the  lia- 
bility of  such  patients  to  develop  hysteria,  neurasthenia,  or 
insanity. 

Compression  of  the  Brain.— The  causes  of  brain- 
compression  are  hemorrhage,  depressed  fracture,  tumor,  in- 
35 


546  MODERN  SURGERY. 

flammatory  exudate,  pus,  and  foreign  bodies.  Death  tends 
to  happen  from  respiratory  failure,  not  from  heart-failure 
(Horsley). 

Symptoms. — In  great  or  sudden  brain-compression  com- 
plete coma  exists  without  voluntary  movement.  The  skin 
is  hot  and  perspiring ;  the  respirations  are  slow  and  sterto- 
rous, and  the  cheeks  flap  during  expiration  ;  the  pulse  is  slow 
and  full,  and  may  be  irregular;  the  pupils  are  somewhat 
dilated,  and  do  not  respond  readily  to  light.  In  a  unilateral 
compression  the  pupil  on  the  side  of  the  compressing-cause 
is  apt  to  be  much  dilated  if  the  compression  is  affecting  the 
base  of  the  brain.  In  cerebral  compression  there  are  usually 
retention  of  urine,  and  often  incontinence  of  feces  ;  paraly.sis 
exists,  which  may  be  very  limited  (monoplegia),  may  be  of 
one  side  (hemiplegia),  or  may  be  general.  In  hemorrhage 
into  the  interior  of  the  brain  the  unconsciousness  is  imme- 
diate or  nearly  so.  In  bleeding  from  the  middle  meningeal 
artery  a  period  of  consciousness  intervenes  between  the  in- 
jury and  the  coma,  in  which  period  blood  collects  and  the 
coma  comes  on  gradually.  In  compression  from  depressed 
fracture  or  from  a  foreign  body  the  symptoms  usually  come 
on  at  once,  but  they  may  be  deferred  for  some  hours.  Com- 
pression from  inflammation  or  pus  begins  gradually  after  a 
considerable  time  has  elapsed. 

A  diagnosis  must  be  made  between  coma  due  to  brain- 
injury  and  the  comatose  conditions  of  apoplexy,  uremia, 
epilepsy,  hysteria,  diabetes,  opium-poisoning,  and  alcohohc 
intoxication.  In  hospital  practice  cases  of  unconsciousness 
without  a  known  hi.story  are  frequent.  In  attempting  this 
diagnosis  examine  carefully  for  any  evidence  of  traumatism, 
and  inquire  as  to  how  and  where  the  patient  was  found,  if 
any  fit  occurred,  and  if  a  bottle  or  a  pill-box  was  found  near 
by  or  in  the  pockets.  The  surgeon  should  himself  exam- 
ine the  pockets.  Smell  the  breath  to  notice  alcohol  or 
opium,  but  always  remember  that  a  man  may  be  stricken 
with  apoplexy  while  he  is  drunk,  and  may  fracture  his 
skull  by  falling  when  under  the  influence  of  opium  or  of 
alcohol.  Draw  the  urine  with  the  catheter  if  any  water  is  in 
the  bladder;  examine  the  urine  for  albumin  and  alcohol, 
and  take  the  specific  gravity.  In  doubtful  cases  of  coma 
use  the  ophthalmoscope.  In  post-epileptic  coma  the  tempera- 
ture is  never  below  normal,  there  are  no  unilateral  symptoms, 
the  condition  resembles  sleep,  and  the  patient  can  be  aroused. 
Hysterical  coma  occurs  in  boys  and  women ;  there  are  no  ob- 
jective symptoms,  and  the  patient,  though  swallowing  what  is 


DISEASES  AND   INJURIES   OF   THE  HEAD.  547 

put  into  his  mouth,  cannot  be  roused  (Gowers).  In  uremia, 
besides  the  condition  of  the  urine  (and  always  remember 
that  a  person  with  albuminuria  is  apt  to  develop  apoplexy), 
there  is  a  persistent  subnormal  temperature,  and  convulsions 
are  prone  to  occur.  There  is  edema  of  the  legs,  and 
paralysis  and  stertor  are  absent.  In  apoplexy  hemiplegia 
exists,  and  the  initial  temperature  is  for  a  short  time  sub- 
normal. A  single  convulsion  may  have  ushered  in  the  case. 
Alcoholic  iDiconsciousncss  is  often  diagnosticated  when  apo- 
plexy really  exists.  A  man  will  smell  of  alcohol  who  has 
had  one  drink,  but  one  drink  will  not  produce  coma  ;  hence 
the  smell  of  alcohol  is  not  conclusive.  In  any  case  of 
doubt  some  hours  of  watching  will  clear  up  the  diagnosis. 
Regard  a  doubtful  case  as  serious  until  the  truth  is  clear. 
In  opiiim-poisoiiing  the  pupils  are  contracted  to  a  pin-point, 
the  respirations  are  usually  slow,  shallow,  and  quiet,  but  may 
be  stertorous,  but  there  is  no  paralysis.  Always  remember 
that  hemorrhage  into  the  pons  will  produce  pin-point  pupils, 
but  it  also  causes  paralysis  (crossed  paralysis  if  in  the  lower 
half  of  the  pons)  and  high  temperature  with  sweating.  In 
opium-poisoning  the  temperature  is  subnormal.  In  diabetic 
coma  the  pupils  will  react  to  a  very  bright  light,  the  tempera- 
ture is  subnormal,  and  the  breath  and  the  urine  smell  like 
chloroform. 

Treatment. — The  treatment  of  brain-compression  depends 
on  the  cause.  Hemorrhage  (extradural  or  subdural)  requires 
trephining  and  arrest  of  bleeding  ;  coma  from  depressed  fract- 
ure demands  trephining  and  elevation  ;  foreign  bodies  must 
be  removed  ;  abscesses  must  be  evacuated  ;  some  tumors  are 
to  be  removed.  In  cerebral  compression,  if  death  is  threat- 
ened by  respiratoiy  failure,  make  artificial  respiration,  and  at 
once  trephine  over  the  supposed  region  of  compression 
(Victor  Horsley).  Horsley  has  shown  that  irrigation  of  the 
head  with  hot  water  is  of  great  value  in  bringing  about  reac- 
tion from  shock  in  cases  of  brain-injury. 

Intracranial  hemorrhage  may  be  either  spontaneous  or 
traumatic.  In  the  vast  majority  of  instances  spontaneous 
hemorrhage  comes  from  the  lenticulo-striate  artery  (Char- 
cot's artery  of  cerebral  hemorrhage),  and  produces  apoplexy, 
a  disease  belonging  to  the  physician  except  in  some  ingra- 
vescent cases,  for  which  ligation  of  the  common  carotid  on 
the  same  side  as  the  rupture  is  indicated.  Traumatism  during 
delivery  is  a  not  unusual  cause  of  hemorrhage  from  the  mid- 
dle meningeal  artery  (Richardiere).  A  traumatic  hemorrhage 
may  take  place  (i)  between  the  bone  and  the  dura  {extra- 


548  MODERN  SURGERY. 

dural) ;  (2)  between  the  dura  and  the  brain  {subdural)  ;  and 
(3)  in  the  brain-substance  {cerebral). 

(i)  Extradural  heraorrhage  arises  from  the  middle 
meningeal  or,  more  often,  from  one  of  its  branches.  A 
spicule  of  bone  may  penetrate  a  venous  sinus  and  pro- 
duce extradural  hemorrhage,  or  a  sinus  may  rupture.  Rupt- 
ure of  the  meningeal  artery  or  one  of  its  branches  is  usu- 
ally, but  not  always,  accompanied  by  fracture ;  in  fact,  in 
some  cases  not  even  a  bruise  can  be  found.  The  ruptured 
vessel  may  be  upon  the  opposite  side,  hence  the  evidence  of 
scalp-injury  is  not  a  certain  sign  of  the  side  of  the  skull 
involved.  The  accident  may  or  may  not  cause  temporary 
unconsciousness ;  but  even  if  it  does,  from  this  unconscious- 
ness the  patient  almost  always  reacts,  and  there  is  a  distinct 
period  of  consciousness  between  the  accident  and  the  lasting 
coma,  the  coma  being  due  to  pressure  from  a  continually  in- 
creasing mass  of  extravasated  blood.  If  the  main  trunk  or 
a  large  branch  is  ruptured,  the  period  of  consciousness  is 
short ;  if  a  small  branch  is  ruptured,  the  period  of  conscious- 
ness is  prolonged  for  hours  or  perhaps  for  days.  As  the  clot 
forms  and  enlarges  the  patient  becomes  heavy,  dull,  stupid, 
and  sleepy,  he  sleeps  so  soundly  he  can  scarcely  be  aroused 
and  snores  loudly,  and  finally  passes  into  stupor  and  then  into 
coma.  The  other  signs  of  this  condition  are  paralysis  of  the 
side  opposite  the  blood-clot  (not  necessarily  of  the  side  op- 
posite the  injury,  for  the  artery  may  rupture  from  contre-coup 
on  the  uninjured  side) ;  this  paralysis  is  apt  at  first  to  be 
localized,  but  it  gradually  and  progressively  widens  its  do- 
main. If  the  clot  extends  toward  the  base,  the  pupil  on  the 
same  side  as  the  clot  ceases  to  react  to  light,  becomes  immob- 
ile and  dilates  widely,  and,  if  the  clot  be  on  the  left  side, 
aphasia  is  noted.  As  the  clot  enlarges  adjacent  centers 
become  involved.  The  face  becomes  paralyzed,  then  the  arm, 
and  finally  the  leg.  Not  unusually  epileptiform  attacks  occur, 
starting  in  discharges  from  the  centers  which  are  irritated  by 
the  advancing  clot  before  their  function  is  abolished  by  press- 
ure. The  pulse  becomes  full,  strong,  usually  slow,  but 
occasionally  frequent ;  the  breathing  becomes  stertorous  ; 
the  temperature  rises,  that  of  the  paralyzed  side  exceeding 
that  of  the  sound  side.  In  a  compound  fracture  the  pressure 
of  escaping  blood  may  force  brain-matter  out  of  the  wound 
(Keen).  In  extradural  hemorrhage  from  a  sinus  the  symp- 
toms cannot  be  differentiated  from  those  produced  by  arterial 
rupture. 

Treatment. — In  treating  extradural    hemorrhage    localize 


DISEASES  AND   INJURIES   OF   THE   HEAD.  549 

the  clot,  not  by  the  seat  of  the  wound  or  contusion,  but 
entirely  by  the  symptoms.  To  reach  the  middle  meningeal 
artery  or  its  anterior  branch,  trephine  one  and  one-fourth 
inches  back  of  the  external  angular  process,  at  the  level  of 
the  upper  border  of  the  orbit  (Kronlein)  (Fig.  164).  If  this 
incision  does  not  expose  the  clot,  trephine  again  at  the  level 
of  the  upper  border  of  the  orbit  and  just  below  the  parietal 
eminence.  The  first  incision  gives  access  to  the  trunk  and 
to  the  anterior  branch  ;  the  second  incision  exposes  the  poste- 
rior branch.  If  signs  indicate  that  the  clot  is  travelling  to 
the  base,  the  trephine  should  be  used  half  an  inch  lower 
than  the  point  first  indicated.  Arrest  bleeding  by  a  suture 
ligature  or  by  packing  (page  266),  and  always  open  the  dura 
and  inspect  the  brain.  By  this  procedure  a  subdural  hem- 
orrhage may  be  discovered  which,  without  it,  would  have 
been  missed.     Drainage  must  be  employed. 

(2)  Subdural  hemorrhage  is  usually  due  to  depressed 
fracture  and  rupture  of  the  middle  cerebral  artery  or  of 
a  number  of  small  vessels.  The  symptoms  are  identical  with 
those  of  extradural  bleeding,  but  are  usually  very  rapid  in 
onset. 

The  treatment  is  trephining  at  the  first  point,  enlarging  the 
opening  upward  and  backward  with  a  rongeur,  opening  the 
dura,  turning  out  the  clot,  Hgating  the  bleeding  point  or 
packing,  elevating  any  depression  of  bone,  draining,  and 
stitching  the  dura  with  catgut.  Hemorrhage  from  internal 
pachymeningitis  requires  the  same  treatment. 

(3)  Cerebral  Hemorrhage. — The  symptoms  of  cerebral 
hemorrhage  are  identical  with  those  of  apoplexy.  The  trcat- 
fnent  is  the  same  as  that  for  apoplexy,  except  in  ingravescent 
cases,  when  the  common  carotid  on  the  same  side  as  the 
clot  may  be  ligated. 

Rupture  of  a  sinus  usually  arises  from  compound  fract- 
ure or  during  a  brain-operation.  The  treatment,  if  the 
rupture  happens  from  fracture,  is  trephining.  Enlarge  the 
opening  by  the  rongeur,  pack  with  07ie  large  piece  of  iodo- 
form gauze,  or  catch  the  rent  with  hemostatic  forceps,  leav- 
ing them  in  place  for  three  or  four  days,  or  apply  a  lateral 
ligature  or  a  suture  ligature.  Elevate  depressed  bone.  In 
rupture  during  an  operation  control  hemorrhage  by  packing. 

Fractures  of  the  skull  may  be  simple,  compound,  de- 
pressed, non-depressed,  or  punctured.  They  are  divided  into 
fractures  of  the  vault,  usually  due  to  direct  force,  and  fract- 
ures of  the  base,  due  to  extension  of  fractures  of  the  vault, 
to  indirect  violence  (a  fall  upon  the  feet,  the  buttocks,  or  the 


550 


MODERN  SURGERY. 


vault),  to  forcing  of  the  condyles  of  the  lower  jaw  against  or 
through  the  base,  or  to  foreign  bodies  breaking  through  the 
orbit,  vault  of  the  pharynx,  the  ear,  or  the  roof  of  the  nos- 
trils. Fracture  by  contre-coup,  which  occurs  on  the  side 
opposite  the  application  of  the  violence,  is  very  rare.  Fract- 
ures of  the  skull  are  uncommon  in  early  youth,  but  they 
are  much  more  frequent  in  the  aged.  Usually  the  entire 
thickness  of  the  bone  is  fractured,  but  either  the  outer  or 
the  inner  table  may  be  broken  alone.  In  complete  fractures 
the  inner  table  is  broken  more  extensively  than  is  the  outer 
table,  because  the  inner  table  is  the  more  brittle,  because  the 
force  diffuses,  and  also,  as  Agnew  taught,  because  the  inner 
table  is  part  of  a  smaller  curve  than  is  the  outer  table,  and 
violence  forces  bone-elements  together  at  the  outer  table,  but 
tears  them  asunder  at  the  inner  table  (Figs.  173,  174). 


Fig.  173.— Section  of  outer  and  inner  Fig.  174. — Greater  yielding  of  the  inner 

tables,  with  two  parallel  lines  (after  Ag-  table  than  of  the  outer  after  the  applica- 

nev/).  tion  of  violence  (after  Agnew). 

Fractures  of  the  Vault. — A  fracture  of  the  vault  of  the 
skull  may  be  simple  and  undepressed,  or  it  may  be  depressed, 
compound,  or  comminuted.  A  mere  crack  may  exist  in  a 
bone,  and  if  a  rent  exists  in  the  soft  parts,  a  bit  of  dirt  or  a 
hair  may  be  caught  in  the  crack.  Fractures  of  the  vault 
arise  from  direct  force.  A  fissure  may  escape  recognition, 
although  in  some  cases  percussion  gives  a  "cracked-pot" 
sound.  Any  considerable  depression  can  be  detected.  Tn  a 
simple  fracture  occasionally  the  cerebrospinal  fluid  collects 
under  the  scalp  and  forms  a  tumor  which  pulsates  and  be- 
comes tense  on  forcible  expiration  (puffy  tumor  of  Pott), 
Compound  fractures  can  be  readily  recognized,  but  do  not 
mistake  a  suture,  a  Wormian  bone,  or  a  tear  in  the  pericra- 
nium for  a  fracture.  A  fissured  fracture  is  marked  by  a  dark 
line  of  blood  which  sponging  will  not  remove.  Fracture  of 
the  inner  table  alone  can  only  be  suspected  (Keen).  The 
prognosis  of  fractures  of  the  vault  depends  upon  the  extent 
of  brain-injury  rather  than  upon  the  extent  of  bone-injury. 
Simple  fractures  unite  by  bone;  compound  fractures  with 
loss  of  bone  unite  only  by  fibrous  tissue.     The  dangers  may 


DISEASES  AND   INJURIES   OF   THE  HEAD.  55 1 

be  immediate  (hemorrhage,  brain-injury,  and  septic  inflamma- 
tion) or  be  distant  (epilepsy,  insanity,  and  persistent  headache). 
Treatment. — A  simple  fracture  without  depression  and 
without  brain-symptoms  is  treated  expectantly  (by  rest, 
quiet,  low  diet,  purgation,  moderate  elevation  of  and  cold  to 
the  head,  and  arterial  sedatives).  A  simple  fracture  with 
moderate  depression  and  without  cerebral  symptoms  is 
treated  expectantly,  and  so  also  is  a  simple  fracture  in  which 
symptoms  existed  but  are  abating.  Simple  fracture  with 
marked  depression  requires  immediate  trephining,  even  when 
brain-symptoms  are  absent.  Some  surgeons  make  an  excep- 
tion in  young  children,  and  wait  awhile  before  trephining, 
in  the  expectation  that  the  expansile  brain  will  lift  the  de- 
pressed but  elastic  bone  up  to  the  level.  Trephining  in 
cases  where  no  symptoms  exist,  although  there  is  marked 
depression,  often  prevents  disastrous  consequences  arising 
in  the  future,  and  is  known  as  "  preventive  trephining " 
(Agnew,  Keen,  Horsley,  Macewen,  v.  Bergmann,  and 
others).  In  all  compound  fractures,  shave  and  asepticize 
the  entire  scalp,  enlarge  the  incision,  and  explore  the  bone. 
If  a  fissure  exists  it  must  be  asepticized,  and  if  a  hair  or  other 
foreign  body  is  found  in  it,  in  order  to  effect  removal  and  se- 
cure asepsis  the  outer  table  of  the  skull  must  be  cut  away 
with  a  chisel,  the  fissure  being  thus  converted  into  a  broad 
groove.  In  a  compound  fracture  with  much  depression, 
trephine,  elevate,  and  irrigate.  In  any  fracture,  trephine  if 
distinct  symptoms  exist.  In  punctured  wounds  of  the  brain 
(punctured  fractures),  ahvays  trephine,  open  the  dura,  and 
disinfect  (Keen).  In  any  case  of  fracture  of  the  vault  where 
trephining  has  been  performed,  it  is  wise  to  open  the  dura 
and  examine  the  brain. 

Fractures  of  the  Base. — A  fracture  of  the  base  of  the 
skull  may  exist  in  only  one  of  the  three  fossje,  in  two  of 
them,  or  it  may  involve  all.  The  middle  fossa  is  oftenest 
involved.  Fracture  of  the  posterior  fossa  is  the  most  fatal. 
These  fractures  may  be  due  to  direct  violence,  to  indirect 
force,  and  to  extension  of  a  fracture  of  the  vault.  Extension 
from  the  vault  is  always  by  the  shortest  route.  Fracture  by 
direct  violence  may  arise  from  the  penetration  of  the  nasal 
roof,  the  orbital  roof,  or  the  pharyngeal  roof  by  a  foreign 
body.  The  posterior  fossa  may  suffer  from  a  fracture  by 
direct  violence  applied  to  the  neck.  Fractures  by  indirect 
force  may  arise  from  blows  upon  the  frontal  bone  (the  orbital 
portion  of  the  frontal  or  the  cribriform  process  of  the  eth- 
moid breaking),  from  falls  upon  the  chin  (the  condyle  of  the 


552  MODERN  SURGERY. 

jaw  breaking  the  middle  fossa),  or  from  falls  upon  the  but- 
tocks, the  knees,  or  the  feet  (fracture  occurring  in  the  poste- 
rior fossa).  The  base  is  very  rarely  broken  by  contre-coup 
(Treves). 

Symptoms. — Fractures  of  the  base  of  the  skull  are  apt  to  be 
compound.  A  solution  of  continuity  in  the  pharynx,  roof 
of  the  nares,  orbit,  or  ear,  permits  access  of  air  to  the  seat 
of  fracture  and  allows  blood  and  cerebrospinal  fluid  to  flow 
externally.  In  fracture  of  the  anterior  fossa  the  fracture 
may  be  compound,  because  of  laceration  of  the  mucous  mem- 
brane of  the  nares  or  of  the  conjunctiva.  Blood  may  run 
from  the  nose,  its  source  being  the  vessels  of  the  mucous 
membrane  or  the  dura,  the  fracture  being  compound.  Epis- 
taxis  does  not  prove  the  fracture  to  be  compound,  but  only 
suggests  it ;  but  if  the  epistaxis  is  prolonged,  the  probability 
is  greatly  increased;  and  if  the  flow  of  blood  is  succeeded  by  a 
flow  of  cerebrospinal  fluid  the  diagnosis  of  compound  fracture 
is  positive.  Cerebrospinal  fluid  only  appears  when  the  mu- 
cous membrane,  the  dura,  and  the  arachnoid  are  each  lacer- 
ated (Treves).  In  fractures  of  the  anterior  fossa  blood  is  apt 
to  flow  into  the  orbit,  producing  subconjunctival  ecchymosis, 
and  some  blood  is  often  swallowed  and  vomited.  In  fractures 
of  the  middle  fossa  blood  may  flow  from  the  ear  through  a 
tear  in  the  tympanum,  its  source  being  the  vessels  of  the 
tympanum,  the  meningeal  vessels,  or  a  sinus.  Blood  may 
flow  through  the  Eustachian  tube  and  come  from  the  nose, 
may  be  spit  up,  or  may  be  swallowed  and  vomited.  In  many 
cases  a  quantity  of  cerebrospinal  fluid  flows  from  the  ear,  the 
discharge  being  increased  by  expiratory  effort  and  a  position 
which  favors  gravity.  The  cerebrospinal  fluid  must  not  be 
confused  with  either  blood-serum  or  liquor  Cotunnii.  The 
cerebrospinal  fluid  is  always  present  in  large  amount ;  the 
liquor  Cotunnii  can  only  be  present  in  minute  amount. 
Blood-serum  is  highly  albuminous ;  cerebrospinal  fluid  is 
a  serous  fluid  of  very  low  specific  gravity,  never  shows  more 
than  a  trace  of  albumin,  and  contains  considerable  chlorid 
of  sodium  and  in  some  instances  sugar,  which,  when  present, 
reacts  to  Trommer's  and  to  Moore's  tests,  but  does  not  reflect 
polarized  light  nor  ferment  with  yeast  (Keetley,  from  Collins). 
Treves  states  ^  that  cerebrospinal  fluid  cannot  flow  from  the 
ear  in  fractures  of  the  middle  fossa  unless  (i)  the  line  of 
fracture  crosses  the  internal  meatus,  (2)  unless  the  prolonga- 
tion of  the  membranes  into  the  meatus  is  torn,  (3)  unless  a 
communication  exists  between  the  internal  ear  and  tympa- 

^  Applied  Anatomy. 


DISEASES  AND   INJURIES   OF   THE   HEAD.  553 

num,  and  (4)  unless  the  drum-membrane  is  torn.  Miles  of 
Edinburgh '  claims  that  bleeding  from  the  ear  followed  by  a 
flow  of  cerebrospinal  fluid  is  not  pathognomonic  of  fracture 
of  the  middle  fossa  of  the  base.  He  maintains  that  when 
the  drum  is  ruptured  we  may  have  these  signs,  when  bone 
is  not  broken,  the  chief  source  of  the  blood  being  the  vessels 
of  the  pia  and  temporosphenoidal  lobe,  the  blood  and  cere- 
brospinal fluid  flowing  inside  the  sheath  of  the  auditory 
nerve,  passing  into  the  vestibule,  through  the  lamina  crib- 
rosa,  and  from  the  vestibule  into  the  middle  ear,  finding  exits 
from  this  space  by  way  of  the  Eustachian  tube,  and  also 
through  the  rent  in  the  drum-membrane.  Profuse  serous 
discharge  may  flow  from  the  ear  after  an  injury  without  fract- 
ure when  the  drum  is  ruptured,  the  fluid  coming  from  the 
cells  of  the  mastoid.  It  must  be  understood  that  fracture 
of  the  base  may  exist  when  there  is  no  flow  of  blood  or  of 
serous  fluid.  A  fracture  of  the  middle  fossa  is  usually  com- 
pound, made  so,  even  when  the  drum  is  not  ruptured,  by 
the  Eustachian  tube.  In  fracture  of  the  posterior  fossa  blood 
accumulates  beneath  the  deep  fascia  and  produces  discolora- 
tion in  the  line  of  the  posterior  auricular  artery  (Battle's 
sign),  the  discoloration  first  appearing  near  the  tip  of  the 
mastoid.  The  discoloration  appears  in  the  line  of  nerves 
and  vessels  which  emerge  from  the  deep  fascia,  the  vessels 
passing  through  openings  and  the  extravasated  blood  emerg- 
ing from  the  same  openings.  Fractures  of  the  posterior  fossa 
are  apt  to  be  compound  through  the  pharynx,  and  in  such 
cases  the  patient  spits  or  vomits  blood.  Compound  fract- 
ures of  the  posterior  fossa  are  more  fatal  than  fractures  in 
either  of  the  other  fossae.  Fractures  of  the  base  are  apt  to 
be  associated  with  paralysis  of  cranial  nerves.  Optic  neuritis 
often  arises  after  the  first  week.  Keen  says  that  in  fractures 
of  the  base  the  temperature  is  subnormal  during  the  shock, 
rises  to  100°  to  101°,  falls  again  to  a  little  below  normal,  and 
remains  normal  or  subnormal  unless  there  be  inflammation 
or  sepsis. 

Treatment. — In  treating  a  compound  fracture  of  the  base 
of  the  skull,  collect  any  serous  discharge  and  analyze  it,  and 
disinfect  any  cavity  involved.  In  fractures  of  the  middle  fossa 
with  ruptured  drum  clean  the  ear  mechanically,  wash  it  out 
with  hydrogen  peroxid  and  with  a  stream  of  warm  corrosive- 
sublimate  solution  of  a  strength  of  i  :  2000  (turn  the  head 
toward  the  affected  side  while  washing,  so  that  the  mercurial 
solution  will  not  run  down  the  Eustachian  tube),  pack  with 

'  Edinburgh  Med.  Jour.,  Nov.,  1895. 


554  MODERN  SURGERY. 

iodoform  gauze,  and  apply  an  antiseptic  dressing.  Several 
times  daily  the  ear  is  to  be  irrigated,  and  insufflated  with  iodo- 
form. The  nasopharynx  must  be  frequently  irrigated  with 
normal  salt  solution  or  boric-acid  solution,  and  insufflated 
with  iodoform.  The  conjunctival  sac  is  frequently  irrigated 
with  boric-acid  solution.  If  after  a  head-injury  blood  accu- 
mulates back  of  the  drum,  this  membrane  should  be  incised 
to  permit  of  drainage  and  disinfection.  In  fractures  of  both  the 
middle  and  anterior  fossae  the  nasopharynx  must  always  be 
cleaned.  The  exact  method  depends  on  the  choice  of  the 
surgeon.  We  may  wash  out  these  cavities  frequently  with 
hot  water,  next  with  peroxid  of  hydrogen,  and  finally  with 
boric-acid  solution,  or  can  use  normal  salt  solution.  Insuf- 
flate the  nasopharynx  with  iodoform,  and  pack  the  nose 
with  iodoform  gauze  (Keen,  Dennis) ;  also  cleanse  the  con- 
junctival sac  frequently.  In  some  cases  drainage  has  been 
obtained  from  the  anterior  fossa  by  breaking  down  the  crib- 
riform plate  and  introducing  a  tube  through  the  nostril 
(Allis),  and  from  the  middle  fossa  by  trephining  above  and 
behind  the  external  auditory  meatus.  In  a  compound  fract- 
ure of  the  orbit  disinfect  and  drain.  It  may  be  necessary  to 
trephine  the  roof  of  the  orbit  for  drainage.  In  fracture  of 
the  posterior  fossa  examine  to  see  if  the  fracture  is  com- 
pound, into  the  pharynx,  and  if  it  is  cleanse  with  great  care 
the  nasopharynx,  and  mouth,  as  previously  directed.  In  a 
very  extensive  fracture  of  the  base,  besides  use  of  the 
methods  set  forth  above,  the  entire  head  should  be  shaved 
and  a  plaster  cap  be  applied.  Cases  of  fracture  of  the  base 
must  be  put  into  a  quiet  and  darkened  room  and  be  kept 
upon  a  low  diet,  sleep  being  secured,  and  the  bowels  and 
bladder  being  attended  to.  If  we  are  not  sure  whether  a 
fracture  exists  or  not,  keep  the  man  quiet  and  in  a  darkened 
room,  and  on  a  low  diet.  Attend  to  the  bladder,  keep  the 
bowels  loose,  examine  the  nasopharynx  with  mirrors  and 
the  drum  through  a  speculum. 

Wounds  of  the  brain  are  produced  by  violence  and  by 
foreign  bodies  (knives,  bullets,  etc.).  Except  when  due  to 
penetration  of  a  fontanelle  in  a  child  or  of  a  parietal  foramen 
in  adults,  wounds  of  the  brain  are  accompanied  by  fracture 
of  the  skull.  These  wounds  are  very  dangerous :  foreign 
bodies  (bone,  hair,  clothing,  etc.)  are  often  lodged  in  the 
brain,  hemorrhage  is  usually  severe,  and  sepsis  is  almost 
inevitable  without  proper  treatment.  These  cases  are  very 
fatal,  though  some  astonishing  recoveries  are  on  record. 

The  syraptoms  of  brain-wounds  may  be  slight  and  long- 


DISEASES  AND   INJURIES   OF  THE  HEAD.  555 

deferred  or  may  be  immediate  and  overwhelming ;  they 
depend  upon  the  site  and  extent  of  the  injury.  Localizing 
symptoms  may  exist,  and  encephaHtis  with  coma  is  apt  to 
arise.     Abscess  not  unusually  follows. 

In  treating  wounds  of  the  brain  always  shave  the  entire 
scalp  and  examine  the  weapon,  if  possible,  to  see  if  a  piece 
were  broken  off.  Asepticize,  enlarge  the  wound,  trephine, 
arrest  bleeding,  elevate  any  depression,  remove  foreign 
bodies,  irrigate  the  wound,  suture  the  dura,  drain,  and  dress. 

Gunshot- wounds  of  the  Head. — A  penetrating  wound 
is  one  in  which  the  bullet  enters  the  head,  but  does  not 
emerge ;  a  perforating  wound  is  one  in  which  the  bullet 
passes  through  the  head  and  emerges.  The  bullet  of  the 
modern  rifle  will  rarely  lodge,  but  a  pistol-bullet  will  often 
lodge.  The  wound  of  entrance  is  small ;  the  wound  of  exit 
is  large.  At  the  wound  of  entrance  the  inner  table  is  more 
extensively  fractured  than  the  outer  table  ;  at  the  wound  of 
exit,  the  outer  table  is  more  widely  broken  than  the  inner 
table.  In  these  cases  there  is  always  great  concussion,  and 
concussion-symptoms  exist  even  when  the  bullet  has  not 
entered  the  brain.  In  moderate  concussion  the  action  of 
the  heart  is  retarded ;  in  severe  concussion  it  is  accelerated.^ 
A  bullet  may  be  lodged  within  the  cranium  when  merely  a 
fracture  without  a  bullet-hole  can  be  detected.  In  these 
cases  the  bullet  produces  a  fracture  and  enters  the  cranium, 
and  then  the  depressed  bone  flies  back  into  place  (v.  Berg- 
mann).  In  such  cases  if  complete  perforation  occurs,  the 
one  existing  opening  is  the  opening  of  exit.  A  bullet 
may  lodge  in  the  bone,  between  the  dura  and  the  bone, 
in  the  brain,  between  the  dura  and  bone  of  the  opposite 
side,  or  in  the  bone  of  the  opposite  side,  in  the  nasal  fossa, 
maxillary  antrum,  or  orbit.  Always  examine  the  side  of  the 
head  opposite  to  the  wound  of  entrance  to  determine  if  there 
is  any  bulging  or  fracture.  A  bullet  may  pass  or  cross 
the  brain  and  be  deflected  from  the  inner  surface  of  the 
skull  (Fluhrer).  Ruth  does  not  believe  the  bullet  can  re- 
bound from  the  opposite  wall.^  The  secondary  symptoms  of 
gunshot-wounds  of  the  head  are  varied  and  uncertain,  and 
may  not  be  observed  at  all  before  death.  Fowler  wisely 
points  out  that  a  patient  with  a  gunshot-wound  of  the 
head  may  have  also  received  other  injuries,  and  the  other 
injuries  may  be  in  part,  at  least,  responsible  for  cerebral 
symptoms. 

^  Fowler,  in  Annals  of  Surgery,  Nov.,  1895. 

'^  See  the  instructive  article  by  Fowler,  in  Annals  of  Surgery,  Nov.,  1895. 


556  MODERN  SURGERY. 

Treatment. — Bring  about  reaction  (see  Concussion).  In 
severe  cases  apply  heat  to  the  head,  and  make  artificial  respi- 
ration. It  will  sometimes  be  necessary  to  operate  while  arti- 
ficial respiration  is  being  made.  In  treating  gunshot-wounds 
of  the  head  shave  and  asepticize  the  whole  scalp,  disinfect  the 
entire  track  of  the  ball,  and  arrest  hemorrhage  at  the  wounds 
of  entrance  and  exit,  using  the  rongeur  to  expose  the  bleed- 
ing points  if  the  bullet  be  large,  employing  the  trephine  if  it 
be  small.  If  the  bullet  has  emerged  and  has  been  picked  up, 
examine  it  to  see  if  it  is  entire.  The  bullet,  if  retained,  is  to  be 
sought  for.  Place  the  head  in  such  a  position  that  the  track 
of  the  ball  will  be  vertical,  then  introduce  Fluhrer's  aluminum 
probe  and  let  it  find  its  way  by  gravity.  The  probe  may  find 
the  ball  near  the  wound  of  entrance,  in  which  case  extract 
the  ball  with  forceps ;  or  the  probe  may  find  the  ball  near 
the  opposite  side  of  the  head,  in  which  case  make  a  counter- 
opening  through  the  bone  at  a  point  the  probe  would  touch 
if  it  were  pushed  entirely  across.  Take  a  new  and  clean 
rubber  catheter  (No.  9,  French),  insert  a  stylet,  and  carry  the 
catheter  through  the  wound  (Keen).  Knowing  the  depth  of 
the  ball,  search  for  it  around  the  catheter-tube  as  an 
axis,  and  when  found  extract  it.  After  extraction  drain 
the  wound  by  means  of  a  tube.  When  a  counter-opening 
exists  drain  through  and  through.  If  the  ball  cannot  be 
detected,  drain  by  a  tube  carried  to  the  depths  of  the  wound. 
After  dressing  always  place  the  head  in  a  position  favor- 
able for  drainage.  Fluhrer  tells  us  that  when  a  counter- 
opening  fails  to  disclose  the  bullet,  use  the  new  opening 
as  a  doorway  through  which  to  search  for  the  ball.  He 
believes  the  bullet  is  not  unusually  deflected.  The  angle 
of  reflection  is  somewhat  greater  than  the  angle  of  in- 
cidence, and  the  bullet  is  apt  to  fall  a  little  toward  the 
base.  Splinters  of  bone  are  often  driven  into  the  brain 
by  a  bullet,  and  these  are  removed  whether  the  ball  is 
found  or  not.  Several  varieties  of  probes  have  been  com- 
mended. Fluhrer  uses  a  large-sized  aluminum  probe.  Senn 
uses  an  instrument  shaped  like  the  Nelaton  probe,  but  of  the 
same  diameter  as  the  bullet.  (Of  course,  the  porcelain  probe 
will  not  show  a  black  mark  from  contact  with  a  modern 
bullet.)  Fowler  uses  a  graduated  pressure-probe ;  so  long 
as  the  pressure  is  within  the  limits  of  the  spring,  as 
shown  by  the  scale,  the  probe  is  in  the  bullet-track. 
Girdner's  telephonic  probe  is  a  valuable  aid  to  diagnosis. 
Recently  bullets  have  been  located  by  the  Rontgen  rays. 
There  can  be  no  doubt   that   many  gunshot- wounds  have 


DISEASES  AND   INJURIES   OF   THE   HEAD.  557 

been  recovered  from  without  operation,  and  there  can  be  no 
doubt  that  many  deaths  follow  operation  (about  33^  per  cent., 
according  to  Hahn).  Von  Bergmann  is  so  impressed  with 
these  facts  that  he  does  not  operate  when  symptoms  are 
absent. 

Fungus  cerebri  (hernia  of  the  brain)  rarely  contains  true 
brain-substance.  It  is  in  most  instances  a  growth  from  the 
neuroglia.  Hernia  cerebri  cannot  occur  if  the  dura  is  not 
opened ;  it  is  rare  in  any  case  unless  the  brain  is  damaged, 
and  is  most  frequent  after  septic  wounds.  In  any  brain- 
operation  where  the  dura  is  opened  suture  it ;  or,  if  there  be 
a  great  gap  in  the  dura,  turn  in  a  flap  of  pericranium,  its 
bone-forming  surface  being  upward,  and  stitch  this  mem- 
brane to  the  dura  (Keen).  The  evidence  of  brain-hernia  is  a 
protruding  mass  which  is  soft,  lobulated,  of  a  dirty-white 
color,  pulsating,  painless  to  the  touch,  often  bleeding,  and 
sometimes  discharging  cerebrospinal  fluid.  In  treating 
brain-hernia  employ  antiseptic  dressings.  Skin-grafting 
benefits  some  cases.  Pressure  is  dangerous.  Excision  by 
the  knife  or  cautery  does  no  good.  After  healing,  a  depres- 
sion marks  the  site  of  the  hernia. 

Traumatic  inflammation  of  the  brain  and  its  mem- 
branes is  divided  into  encepJialitis  or  cerebritis,  inflammation 
of  the  cerebrum  ;  cerebellitis,  inflammation  of  the  cerebellum  ; 
meningitis,  inflammation  of  the  meninges  ;  ai-achiitis,  inflam- 
mation of  the  arachnoid ;  pachynieningitis,  inflammation  of 
the  dura;  and  leptomeningitis,  inflammation  of  the  arachnoid 
and  pia. 

Pachymeningitis. — Inflammation  of  the  external  layer 
of  the  dura  is  called  pachymeningitis  externa.  It  may  arise 
from  tumor,  caries,  necrosis,  middle-ear  disease,  sunstroke, 
or  traumatism.  Syphilis  is  a  not  unusual  cause.  The  other 
membranes  may  become  involved.  Suppuration  may  arise, 
having  extended  by  contiguity  from  neighboring  parts.  The 
symptoms  of  pachymeningitis  externa  are  uncertain.  They 
resemble  often  those  of  leptomeningitis  (page  558).  Pressure- 
symptoms  may  arise.  Headache  is  always  present.  Paralysis 
may  or  may  not  exist.  If  pus  forms,  the  ordinary  constitu- 
tional symptoms  of  suppuration  arise  (high  temperature  and 
sweats),  not  the  symptoms  of  abscess  in  the  brain.  In  a 
severe  case  the  other  membranes  become  involved. 

The  treatment  consists  in  removing  the  cause  (carious 
bone,  pus,  middle-ear  disease).  In  pachymeningitis  from 
traumatism  it  is  sometimes  advisable  to  trephine  in  order 
to   drain  inflammatory  products ;  in  a  case  with  localizing 


558  MODERN  SURGERY. 

symptoms  always  trephine ;  in  an  ordinary  case,  without  pus 
and  with  no  evidences  of  traumatism,  use  wet  cups  back  of 
the  mastoid  processes,  apply  an  ice-bag  to  the  head,  and 
purge  by  means  of  calomel.  Use  iodid  of  potassium  in  most 
cases.     If  sunstroke  is  the  cause,  treat  accordingly. 

Pachymening-itis  interna  may  extend  from  the  pia, 
or  may  extend  from  the  outer  layer  of  the  dura.  The  form 
known  as  hematoma  of  the  dura  mater,  or  pachymeningitis 
interna  haemorrhagica,  may  arise  during  infectious  diseases 
(typhoid  fever  and  rheumatism),  in  persons  of  the  hemor- 
rhagic diathesis,  in  diseases  causing  atrophy  of  the  brain, 
in  chronic  diseases  of  the  heart  and  kidneys,  and  in  syph- 
ilitics.  Among  the  exciting  causes  are  traumatism,  in- 
flammation in  adjacent  parts,  and,  especially,  the  abuse  of 
alcohol.  In  this  disease  blood  is  extravasated  on  the  inner 
surface  of  the  dura.  Many  observers  do  not  class  hemor- 
rhagic pachymeningitis  as  inflammation,  but  regard  the 
hemorrhage  as  primary. 

The  symptoms  of  internal  pachymeningitis  are  very 
chronic,  are  not  characteristic,  and  tnay  be  absent.  They 
consist  usually  of  persistent  headache  and  apoplectiform 
attacks,  with  contraction  of  the  pupil,  slow  pulse,  and  vom- 
iting. ■  Choked  disk  is  not  infrequent,  localizing  symptoms 
may  be  made  out,  and  coma  is  apt  to  arise. 

The  treatment  is  the  same  as  that  for  external  pachy- 
meningitis. 

Acute  leptomeningitis  is  a  purulent  inflammation  of 
the  soft  membranes  of  the  brain.  The  pathological  changes 
can  be  noted  in  the  pia  and  in  the  brain-substance.  The  brain 
is  edematous,  the  pia  purulent,  the  convolutions  are  flattened, 
the  ventricles  are  distended  with  fluid,  and  hemorrhages 
occur  into  the  brain-substance.  Pus  may  be  localized  upon 
the  pia,  but  it  is  usually  diffused  over  one  hemisphere  or 
over  both.  Various  organisms  may  be  found,  especially 
streptococci,  staphylococci,  and  diplococci.  In  some  cases  we 
find  the  bacillus  pyocyaneus  or  the  bacillus  pyocyaneus 
foetidus,  which  is  identical  with  the  colon  bacillus  and  with 
the  bacillus  meningitis  purulenta  (Park).  Saprophytic  or- 
ganisms are  occasionally  present.  This  disease  may  be  acute 
or  chronic,  and  a  severe  case  is  spoken  of  as  encephalitis. 
Secondary  leptomeningitis  is  apt  to  affect  the  convexity ; 
primary  leptomeningitis  is  apt  to  aflect  the  base  (Hirt). 

The  causes  of  leptomeningitis  are  epidemic  cerebro- 
spinal fever,  tuberculosis,  acute  general  diseases  (pneu- 
monia, typhoid,  erysipelas,  and  rheumatism),  bone-diseases, 


DISEASES  AND  INJURIES   OF  THE  HEAD.  559 

traumatisms,  middle-ear  disease,  syphilis,  and  sunstroke. 
The  tissues  of  the  pia  and  the  cerebrospinal  fluid  con- 
tain diplococci  identical  with  pneumococci.  Infection  may 
take  place  by  various  avenues.  It  may  pass  from  the  nose 
by  way  of  the  Eustachian  tube  to  the  ear,  or  from  the  nose 
to  the  frontal  sinus  or  ethmoid  sinuses  (Hirt),  and  from 
these  situations  to  the  brain.  It  may  pass  from  the  middle 
ear  or  mastoid  to  the  membranes  of  the  brain.  In  fractures 
at  the  base  the  organisms  enter  by  way  of  the  pharynx  and 
the  Eustachian  tube,  or  the  ear.  The  symptoms  of  acute 
leptomeningitis  are  violent  headache  persisting  during  delir- 
ium, flushing  of  the  face,  rigidity  of  the  neck,  cerebral  vom- 
iting, a  slow  pulse,  elevated  temperature,  photophobia,  con- 
traction of  the  pupils,  intolerance  of  sound,  hyperesthesia 
of  the  skin  and  muscles,  and  delirium  passing  into  stupor 
and  coma.  A  chill  or  a  succession  of  chills  may  occur. 
Choked  disk,  strabismus,  and  nystagmus  are  not  unusual. 
Convulsions  or  paralyses  may  occur.  Death  is  the  rule 
within  one  week.  The  treatment  usually  consists  of  purga- 
tion with  calomel ;  bleeding  behind  the  mastoid  processes  ; 
cold  to  the  head  ;  warm  baths  with  cold  affusions  to  the 
head ;  iodid  of  potassium,  bromid  of  potassium,  or  morphin 
for  vomiting  and  headache.  Some  surgeons  trephine  in 
order  to  relieve  pressure  and  to  give  exit  to  inflammatory 
products,  and  this  procedure  should  be  employed.  It  gives 
some  hope  of  recovery,  and  the  usually  adopted  medical 
treatment  is  practically  useless ;  should  the  patient  recover, 
he  is  guarded  for  a  long  time  from  physical  exertion,  mental 
excitement,  worry,  irritation,  constipation,  and  insomnia. 

Chronic  Iveptomeningitis  (or  Encephalitis).  —  The 
causes  of  chronic  leptomeningitis  are  the  same  as  those  of 
the  acute  form.  If  traumatism  is  the  cause,  the  inflamma- 
tion arises  at  a  later  period  than  it  would  in  acute  encepha- 
litis. The  symptoms  of  concussion  follow  a  head-injur>'. 
Days,  or  even  weeks,  after  the  accident,  a  series  of  symp- 
toms occur — namely  :  localized  pain  at  the  seat  of  injury, 
often  accentuated  by  tapping ;  listlessness ;  irritability ;  apathy 
regarding  business  affairs  and  home  obligations,  or  profound 
depression  and  hypochondria  with  inability  to  attend  to 
business.  Choked  disk  may  exist.  In  any  case  acute  en- 
cephalitis may  arise,  with  or  without  a  chill.  The  treatment 
of  this  disease  is  symptomatic  unless  local  symptoms  exist. 
Always  operate  if  localizing  .symptoms  are  found.  Intense 
local  pain  justifies  trephining. 

Tubercular  Meningitis  (Acute  Hydrocephalus  ;  Water 


560  MODERN  SURGERY. 

on  the  Brain). — This  inflammatory  condition  is  due  to  the 
bacilH  of  tuberculosis.  In  a  child  affected  with  meningitis  there 
is  often  a  record  of  a  fall,  the  injury  acting  as  an  exciting  cause 
by  establishing  an  area  of  least  resistance.  Prodromal  symp- 
toms are  common  (restlessness,  irritability,  anorexia,  change 
of  character).  The  disease  begins  with  a  convulsion  or  with 
headache,  fever,  and  vomiting  (Osier),  the  child  cries  out 
from  pain  (the  hydrencephahc  cry),  and  the  bowels  are  con- 
stipated. The  pulse  is  rapid  in  the  beginning,  but  later  be- 
comes slow  and  irregular.  The  pupils  are  contracted,  there 
is  muscular  twitching,  and  the  sleep  is  impaired.  The  tem- 
perature is  about  103°.  In  the  second  period  of  the  disease 
the  vomiting  ceases,  constipation  becomes  more  marked,  the 
belly  retracts,  headache  is  not  so  violent,  and  the  patient 
lies  in  a  soporose  condition  interspersed  with  episodes  of 
delirium.  In  this  stage  the  pupils  dilate  and  are  often  un- 
equal, the  head  is  retracted,  convulsions  occur  or  limited 
rigidity  is  noted,  the  respirations  are  sighing,  and  if  a  finger- 
nail is  drawn  along  the  skin,  a  red  hne  develops  (the  tdche 
ch'ebrale,  due  to  vasomotor  paresis).  Squint  and  conse- 
quent double  vision  are  usual.  In  the  last  stage  coma  be- 
comes absolute  and  general  convulsions  or  Hmited  spasms 
are  apt  to  occur.  Optic  neuritis  exists,  and  the  child  passes 
to  death  along  a  road  identical  with  that  of  typhoid  collapse. 
In  some  cases  the  examination  of  cerebrospinal  fluid  with- 
drawn by  lumbar  puncture  throws  light  upon  the  diagnosis. 
In  children  the  base  is  usually  involved,  and  the  disease  is 
apt  to  last  from  two  to  four  weeks ;  in  adults  the  convexity 
of  the  brain  is  usually  involved,  and  death  is  apt  to  occur 
in  a  few  days. 

The  treatment  is  like  that  for  traumatic  meningitis. 

Abscess  of  the  brain  is  a  localized  collection  of  pus. 
The  organisms  found  are  noted  upon  page  558  (Acute 
Leptomeningitis).  The  causes  are  suppurative  otitis  media 
(in  half  of  all  the  cases),  fracture  of  the  skull,  concussion 
of  the  brain,  and  general  septic  diseases.  A  tubercular 
mass  may  caseate  (tubercular  abscess).  The  abscess  may 
be  between  the  dura  and  skull  (extradural),  adhesions 
forming  and  preventing  a  general  leptomeningitis,  between 
the  dura  and  brain  (subdural),  or  in  the  brain-substance 
(cerebral  or  cerebellar).  Leptomeningitis  may  arise  be- 
cause no  adhesions  form,  because  septic  clot  forms  in  veins 
or  sinuses,  or  because  infected  blood  regurgitates  in  sinuses 
(Park).  A  traumatic  abscess  is  generally  beneath  the  area 
to  which  the  traumatism  was  applied,  but  it  may  be  on  the 


DISEASES  AND   INJURIES   OF  THE   HEAD.  56 1 

opposite  side.  The  infection  may  begin  in  the  nose  (page 
553),  the  orbit,  or  the  middle  ear.  Roswell  Park  says  in- 
fection may  pass  along  blood-vessels,  lymph-vessels,  nerve- 
sheaths,  or  the  prolongations  of  the  membranes  which  extend 
outside  of  the  skull.  An  acute  inflammation  of  the  middle 
ear  rarely  causes  abscess,  because  an  acute  inflammation  in 
sound  tissues  causes  the  formation  of  granulation-tissue, 
which  acts  as  a  barrier  to  infection.  Chronic  inflammation 
of  the  middle  ear  is  the  most  frequent  cause  of  abscess.  Park 
tells  us  if  the  roof  of  the  tympanum  is  involved,  it  is  per- 
forated and  abscess  of  the  middle  fossa  ensues ;  if  the  roof  of 
the  tympanum  is  perforated  toward  the  mastoid  antrum,  the 
abscess  arises  in  the  temporosphenoidal  lobe ;  if  the  perfora- 
tion is  toward  the  sigmoid  groove,  the  abscess  forms  in  the 
cerebellum.^ 

Symptoms  of  Abscess  of  the  Cerebral  Substance. — 
The  symptoms  due  to  pus-formation  are  as  follows  :  there 
may  be  an  initial  rise  of  temperature,  but  (except  in  extra- 
dural abscess)  the  temperature  quickly  becomes  normal  or 
subnormal.  Toward  the  end  of  the  case  the  temperature 
may  rise  and  the  fever  become  linked  with  delirium. 
Surface  elevation  of  temperature  over  the  seat  of  the  ab- 
scess is  occasionally  observed.  A  chill  may  or  may  not 
occur.  Anorexia  and  vomiting  are  present.  Urinary 
chlorids  are  diininished  and  the  phosphates  are  increased 
(Somerville).  Symptoms  due  to  pressure  are — headache 
(which  at  first  is  general,  then  local,  and  grows  worse 
later  in  the  case,  and  exists  even  in  delirium  :  this  fact  dis- 
tinguishes it  from  the  headache  of  fever,  which  ceases  in 
delirium) ;  pulse  is  very  slow ;  respiration  tends  to  the 
Cheyne-Stokes  type ;  drowsiness  lapses  into  stupor  and 
stupor  passes  into  coma ;  paralysis  of  the  sphincters  takes 
place;  convulsions  are  common;  sensation  is  rarely  impaired; 
and  paralysis  of  the  basal  nerves  may  occur  (third  and  sixth 
especially).  The  pupil  on  the  same  side  as  the  abscess  is 
dilated  and  fixed.  Choked  disk  is  not  invariably  found ; 
if  it  is  unilateral,  it  is  on  the  same  side  as  the  abscess  ;  if 
it  is  bilateral,  it  is  more  marked  on  the  same  side  as  the 
abscess.  Localizing  symptoms,  spasmodic  and  paralytic, 
depend  upon  the  center  which  is  irritated  or  destroyed. 
In  cerebellar  abscess  there  are  vertigo,  vomiting,  occipital 
headache,  rigidity  of  the  post-cervical  muscles,  and  inco- 
ordination.    Choked  disk  is  often  absent. 

Meningitis  arises  soon  after  an  accident ;  an  abscess,  more 

1  Park,  in  Chicago  Med.  Record,  Feb.,  1895. 


562  MODERN  SURGERY. 

than  a  week,  often  many  weeks,  after  an  accident.  Menin- 
gitis presents  high  temperature  and  the  general  symptoms 
before  outhned.  Mastoid  disease  may  occasion  cerebral 
symptoms  without  abscess,  or  it  may  cause  abscess.  In 
sinus-tlirombosis  there  is  septic  temperature,  the  veins  of  the 
face  and  neck  are  enlarged,  and  a  clot  can  usually  be  felt 
in  the  jugular.  A  tumor  grows  slowly,  usually  presents 
almost  from  the  start  distant  locaHzing  symptoms,  and 
double  choked  disk  is  frequently  present.  In  tumor  the 
temperature  is  apt  to  be  normal. 

Treatment. — If  abscess  is  due  to  ear  disease  with  implica- 
tion of  the  mastoid  cells,  at  once  open  the  mastoid,  and  after 
this  proceed  to  trephine  the  skull  in  order  to  reach  the  ab- 
scess. In  any  case,  if  symptoms  of  abscess  exist,  trephine 
the  skull  at  once.  If  localizing  symptoms  are  present,  open 
over  the  suspected  region.  If  localizing  symptoms  are  not 
present  and  the  cause  is  ear  disease,  trephine  at  Barker's 
point  (Fig.  179).  If  no  pus  is  found  between  the  bone  and 
dura,  open  the  membrane.  When  the  dura  is  opened,  if  the 
abscess  is  subdural  pus  will  be  evacuated  ;  if  the  abscess  is 
in  the  brain-substance,  the  brain  will  bulge  very  much  and 
will  not  be  seen  to  pulsate.  A  grooved  director  is  plunged 
into  the  brain,  in  the  direction  of  the  abscess,  for  two  or  two 
and  a  half  inches  (Keen).  If  pus  is  not  found,  withdraw  the 
director  and  introduce  it  at  another  point.  When  pus  is 
discovered  incise  the  brain  with  a  knife,  enlarge  the  open- 
ing by  inserting  a  closed  pair  of  forceps  and  withdrawing 
the  instrument  with  the  blades  open.  Scrape  away  the 
granulation-tissue  lining  the  abscess-cavity,  irrigate  with  hot 
salt  solution,  and  introduce  a  rubber  drainage-tube  ;  stitch 
the  dura,  but  leave  an  ample  opening  for  the  tube ;  bring  the 
tube  out  through  a  button-hole  in  the  scalp,  and  after  the 
first  two  days  pull  the  tube  out  a  little  every  day  and  cut 
off  a  piece.  If  the  first  trephining  does  not  find  pus,  trephine 
again  at  another  point.  In  cerebellar  abscess  make  a  flap 
with  the  base  up,  and  trephine  or  gouge  away  the  bone  just 
below  the  line  of  the  lateral  sinus.  Puncture  the  brain  as 
for  cerebral  abscess. 

Brain  Disease  from  Suppurative  Bar  Disease. — 
Chronic  disease  of  the  middle  ear  is  apt  to  destroy  the  bone 
between  the  tympanum  and  the  middle  fossa  of  the  skull, 
and  thus  produce  meningitis,  thrombosis  of  the  petrosal  or 
lateral  sinuses,  abscess  of  the  temporosphenoidal  lobe  or  of 
the  cerebellum,  or  extradural  abscess.  Chronic  otitis  media 
also  induces  inflammation    or  suppuration  of  the  mastoid 


DISEASES  AND   INJURIES   OF   THE   HEAD.  563 

cells  (empyema  of  mastoid).  Pus  in  the  mastoid  may  dis- 
charge itself  into  the  middle  ear,  and  from  this  point  into 
the  external  auditory  canal,  through  a  perforation  in  the 
drum-membrane  (especially  in  acute  cases).  In  some  cases 
the  pus  becomes  blocked  up  within  the  mastoid  process. 
Pus  in  the  mastoid  may  after  a  time  break  into  the  cavity 
of  the  cranium  or  into  the  lateral  sinus,  or  may  find  its 
way  externally  and  open  into  the  sheaths  of  muscles  aris- 
ing from  the  mastoid.  It  not  unusually  opens  into  the 
sheath  of  the  digastric  muscle  (Bezold's  abscess).  These 
facts  teach  the  surgeon  that  chronic  ear  disease  should  never 
be  neglected,  but  should,  if  possible,  receive  the  closest  atten- 
tion of  the  specialist.  If  no  perforation  exists  in  the  drum, 
the  surgeon  must  make  one.  In  ordinary  cases  cleanliness 
and  antisepsis  are  sufficient,  the  ear  being  syringed  every 
day  with  a  warm  2  per  cent,  solution  of  common  salt.  If 
only  a  small  drum-perforation  exists,  10  drops  of  pure  alco- 
hol or  of  corrosive-sublimate  solution  (i  :  5000)  are  dropped 
into  the  ear  daily;  but  if  a  large  drum-perforation  exists,  boric 
acid  and  iodoform  (7  to  i)  are  insufflated.  Never  inject  alum. 
A  strong  silver  solution  is  not  safe ;  if  it  is  used,  wash  the 
ear  out  afterward  with  warm  salt  water.  If  granulations  or 
polypi  exist,  they  must  be  removed  (Burnett).  Some  cases 
require  the  removal  of  the  drum-membrane  and  the  ossicles 
of  the  ear.  Many  cases  of  mastoid  necrosis  are  due  to  tuber- 
culosis. If  headache,  vomiting,  and  mastoid  tenderness  exist, 
open  the  mastoid  (see  Operations),  in  order  to  prevent  ab- 
scess of  the  brain.  In  acute  otitis  media  it  is  very  rarely 
necessary  to  open  the  mastoid.  The  middle  ear  is  on  a 
lower  level  than  the  antrum  of  the  mastoid,  and  in  most 
acute  cases  both  the  middle  ear  and  mastoid  cells  drain  safely 
through  a  drum-perforation.  Because  a  man  has  chronic 
otitis  media  it  is  by  no  means  always  necessary  to  trephine 
the  mastoid.  In  many  cases  removal  of  the  ossicles  and 
drum-membrane  effects  a  cure.  In  chronic  otitis  media,  even 
if  the  mastoid  is  trephined,  the  ossicles  and  membrane  ought 
to  be  removed. 

Cerebral  abscess  from  ear  disease  is  almost  always 
in  the  temporospiienoidal  lobe,  but  may  arise  in  the  cere- 
bellum. The  symptoms  are  a  transient  rise  of  temperature 
followed  by  a  subnormal  temperature ;  vomiting ;  mastoid, 
frontal,  and  temporal  pain.  The  mind  is  dull,  and  stupor 
arises  which  passes  into  coma ;  the  bowels  are  constipated ; 
choked  disk  may  be  present ;  and  convulsions  or  spasms  or 
paralyses  may  exist.     Trephine  and  clean  out  the  mastoid, 


564  MODERN  SURGERY. 

and  asepticize  (see  Operations  upon  the  Skull  and  Brain). 
Trephine  at  Barker's  point,  one  and  one-fourth  inches  be- 
hind, and  the  same  distance  above,  the  middle  of  the  exter- 
nal auditory  meatus.  If  pus  is  not  found,  open  the  cerebel- 
lum. 

!^xtradural  Abscess. — The  eye-symptoms  and  pain  are 
the  same  in  this  as  in  cerebral  or  subdural  abscess,  but  the 
temperature  is  different,  rising  to  103°  or  104°.  There  is 
often  con.siderable  tenderness  above  and  behind  the  mastoid. 
Trephine  and  clean  out  the  mastoid;  follow  up  a  bone  sinus 
to  the  abscess,  rongeur  away  the  bone,  avoiding  the  lateral 
sinus,  curet,  irrigate,  and  drain. 

Infective  Sinus-thrombosis  (a  form  of  Pyemia). — The 
symptoins  of  this  disease  present  a  history  of  chronic  ear 
disease ;  general  headache  and  pain  over  the  sinus  arise ; 
violent  rigors  occur ;  and  the  temperature  rises  and  fluctu- 
ates greatly.  The  patient  is  nauseated,  labors  under  vertigo, 
is  very  restless,  is  dull  and  stupid,  sometimes  delirious,  and 
the  muscles  of  the  neck  are  stiff.  Tenderness  and  marked 
edema  are  detected  over  the  mastoid.  When  the  clot  extends 
into  the  jugular  vein  there  is  pain  on  moving  the  head  and  on 
swallowing,  glands  are  swollen,  and  a  clot  may  be  felt  in  the 
neck.  Exophthalmos  and  swelling  of  the  eyelids  point  to 
involvement  of  the  cavernous  sinus  (Jansen).  Choked  disk 
exists  in  about  half  of  all  cases.  There  is  usually  a  profuse 
discharge  of  pus  from  the  ear.  In  early  cases  there  is  throm- 
bosis of  the  lateral  sinus  alone,  or  of  the  lateral  sinus  and 
jugular  vein.  In  advanced  cases  other  sinuses  become  in- 
volved (superior  petrosal,  inferior  petrosal,  both  cavernous, 
the  lateral  sinus  of  the  opposite  side,  the  ophthalmic  veins, 
and  the  torcular  Herophili).  A  patient  with  sinus-throm- 
bosis is  in  great  danger  from  pulmonary  metastasis  and 
septic  meningitis  (Jansen).  Septic  meningitis  is  accompanied 
by  abscess  about  the  sinus. 

The  prognosis  largely  depends  upon  early  recognition. 
The  surgeon  should  open  a  mastoid  before  sinus-thrombosis 
arises,  and  should  evacuate  a  perisinous  abscess  before  a  clot 
forms  in  the  sinus,  or  at  least  before  that  clot  is  septic  (Jan- 
sen). 

Treatment. — Infective  sinus-thrombosis  is  treated  as  fol- 
lows :  open  and  clean  out  the  mastoid,  and  expose  the  sinus  by 
the  use  of  the  chisel  or  rongeur  (Fig.  179).  Open  the  sinus  as 
far  as  the  clot  is  soft,  and  cut  away  the  wall  of  the  sinus.  In- 
troduce a  small  spoon  in  the  sinus  and  carry  it  toward  the 
torcular   Herophili,  and  scrape  away  the  clot  until  blood 


DISEASES  AND   INJURIES   OF  THE   HEAD.  565 

flows.  Stop  hemorrhage  by  plugging  a  piece  of  iodoform 
gauze  into  the  wound  and  toward  the  torcular.  Jansen  op- 
poses removing  the  entire  clot  toward  the  jugular,  and  does 
not  tie  the  jugular,  believing  that  to  do  so  increases  the  dan- 
ger of  thrombosis  of  the  inferior  petrosal  and  cavernous 
sinuses.  Influenced  by  these  views,  Jansen  removes  the  soft 
clot,  but  does  not  disturb  the  solid  clot  toward  the  heart. 
Most  surgeons  differ  with  him,  and  after  opening  the  sinus, 
turning  out  the  clot  and  packing,  proceed  to  ligate  the  jugu- 
lar vein  at  the  level  of  the  cricoid  cartilage.  If,  after  this 
operation,  the  clot  in  the  jugular  becomes  septic,  incise  the 
vein  up  to  the  base  of  the  skull  and  pack.  It  is  obviously 
futile  to  do  any  operation  if  pulmonary  metastasis  has  taken 
place. 

Intracranial  tumors  may  be  true  neoplasms,  may  be  of 
parasitic  origin,  may  result  from  injury,  may  be  tubercular  or 
syphilitic.  Among  these  tumors  are  papillomata,  gliomata, 
sarcomata,  cholesteatomata,  fibromata,  psammomata,  myxo- 
mata,  osteomata,  etc.  (see  Tumors).  Cysts  sometimes  occur. 
The  symptoms  are  diffuse  and  local,  and  are  similar  in 
many  particulars  to  the  symptoms  of  some  other  lesions. 
Among  the  symptoms  of  tumor  are  headache,  slow  speech, 
stupor  or  coma,  slow  pulse,  pain  on  percussion  of  the  cra- 
nium, vertigo,  vomiting,  epileptic  convulsions,  double  choked 
disk,  partial  or  complete  blindness,  extensive  or  limited 
paralyses,  paralysis  of  face,  of  eye-muscles,  or  of  limbs, 
zones  of  anesthesia  and  aphasia,  word-deafness,  word-blind- 
ness, agraphia,  inco-ordination,  and  mental  disturbances. 
The  situation  of  a  tumor  is  determined  from  localizing' 
symptoms,  their  mode  of  onset  and  manner  of  combina- 
tion. In  some  cases  the  symptoms  are  not  character- 
istic, and  in  some  cases  there  are  no  localizing  symp- 
toms. The  nature  of  the  tumor,  its  depth,  and  whether  it 
is  single  or  other  tumors  exist,  is,  if  possible,  determined. 
Localizing  symptoms  may  be  due  to  irritation  or  destruction 
of  functionating  power.  Irritation  causes  spasm  and  destruc- 
tion induces  paralysis.  Convulsions  which  are  local  or  which 
begin  locally  are  known  as  Jacksonian  epilepsy.  A  local 
convulsion  points  to  an  irritative  lesion  of,  or  immediately 
adjacent  to,  the  center  which  presides  over  the  muscular 
movements  of  the  part  convulsed.  Local  paralysis  points 
to  a  destructive  lesion  of  the  center  which  presides  over  the 
movements  of  the  paralyzed  part.  In  some  cases  a  center  is 
damaged  and  the  muscular  movements  it  controls  are  para- 
lyzed, but  the  adjacent  brain-areas  are  irritated  and  the  mus- 


566  MODERN  SURGERY. 

cles  they  represent  are  attacked  with  spasms.  In  some  cases 
an  apparently  paralyzed  part  becomes  convulsed,  the  center 
not  being  completely  destroyed  and  sudden  hyperemia  serv- 
ing to  awaken  spasm.  Always  note  the  order  of  invasion  of 
different  regions  and  observe  if  spasm  is  followed  by  mus- 
cular weakness  or  anesthesia. 

1.  Lesions  in  the  Cortical  Motor  Area. — An  irritative  le- 
sion of  the  lower  third  of  this  area  causes  spasm  of  the  oppo- 
site side  of  the  face,  angle  of  mouth,  or  tongue  ;  and  this  con- 
dition is  often  associated  with  tingling  (Osier).  The  spasm 
may  remain  limited  or  may  extend  widely,  and  may  even 
become  general.  Tumors  of  the  third  frontal  convolution  of 
the  left  side  cause  motor  aphasia.  An  irritative  lesion  of  the 
middle  third  of  the  cortical  area  causes  spasm,  which  is  lim- 
ited to  or  begins  in  the  fingers,  thumb,  wrist,  or  shoulder 
(Osier).  An  irritative  lesion  of  the  upper  third  of  the  cor- 
tical motor  area  causes  spasm,  which  is  limited  to  or  be- 
gins in  the  toes,  ankle,  leg,  or  hip.  In  these  lesions  an  aura 
is  occasionally  felt  in  the  affected  region  before  the  spasm 
begins,  and  there  is  often  numbness  after  the  spasm.  De- 
structive lesions  of  this  region  cause  local  paralysis,  which  is 
often  preceded  by  local  spasm  of  the  same  parts^  and  is  often 
associated  with  local  spasm  of  other  parts. 

2.  Tumors  of  the  prefrontal  region  give  no  localizing 
symptoms,  but  produce  the  general  symptoms.  Mental  dis- 
orders are  apt  to  occur.  The  tumor  may  grow  and  subse- 
quently involve  the  motor  region. 

3.  Tumors  of  the  parieto-occipital  lobe  may  occupy  a 
silent  region  of  this  lobe.  There  may  be  blindness  or  para- 
phasia when  the  angular  gyrus  is  affected. 

4.  Tumors  of  the  occipital  lobe  produce  homonymous 
hemianopsia. 

5.  Tumors  of  the  temporosphenoidal  lobe  frequently 
produce  no  symptoms.  Tumors  in  the  left  lobe  may  cause 
deafness. 

6.  Tumors  of  any  size  in  or  about  the  corpus  striatum  cause 
hemiplegia  by  pressure  upon  the  internal  capsule.  Pressure 
upon  the  optic  thalamus  produces  hemianopsia  and  hemianes- 
thesia. Growths  near  the  basal  ganglion  produce  intense  optic 
neuritis,  and  early  pressure  because  of  distention  of  the  ven- 
tricles. Osier  tells  us  that  tumors  of  the  corpora  quadri- 
gemina  are  apt  to  involve  the  crura,  and  later  the  third  nerve. 
Ocular  symptoms  are  always  present  (loss  of  pupillary  reflex 
and  nystagmus).  If  the  third  nerve  is  involved,  there  are 
paralysis  of  the  motor  oculi  area  on  the  side  of  the  lesion 


DISEASES  AND  INJURIES   OF   THE   HEAD.  567 

(external  strabismus,  dilated  pupil,  and  drop  lid),  and  hemi- 
plegia of  the  opposite  side  of  the  body  from  pressure  upon 
the  crus.     This  condition  is  known  as  a  crossed  paralysis. 

7.  Turaors  of  the  Pons. — Pontine  lesions  produce  symp- 
toms by  pressure  upon  the  particular  nerves  which  come  from 
this  region,  with  or  without  the  evidences  of  pressure  upon  the 
motor  path.  Forms  of  crossed  paralysis  may  exist.  Lesions 
in  the  low^er  half  of  the  pons  may  affect  the  fifth,  sixth,  and 
seventh  nerves  on  the  side  of  the  lesion,  and  the  limbs 
on  the  opposite  side.  The  auditory  nerve  may  be  involved 
in  the  lesion.  In  crossed  paralysis  the  face  on  the  side  of 
the  limb  paralysis  is  usually  not  affected,  but  in  extensive 
tumors  it  may  be  paralyzed.  Conjugate  deviation  may  occur 
atvay  from  \}:iQ  facial  paralysis.  In  tumors  of  the  upper  part 
of  the  pons  the  pupils  may  be  first  contracted  from  irritation 
of  the  third  nerve  nuclei,  and  later  dilated  from  destruction  of 
these  nuclei.  Anesthesia  as  a  result  of  pontine  tumors  is  not 
nearly  so  common  as  is  motor  paralysis,  and  convulsions  are 
rare. 

8.  Tumors  of  the  Medulla.- — An  extensive  lesion  inev- 
itably causes  death.  Cranial  nerves  only  may  be  involved, 
but  crossed  paralysis  may  take  place.  Vomiting  is  com- 
mon, retraction  of  head  is  not  unusual,  respiratory  and  cir- 
culatory disturbances  and  dysphagia  are  frequently  noted; 
sometimes  there  is  numbness,  and  occasionally  there  are 
convulsions ;  usually  there  is  inco-ordination,  because  of 
pressure  upon  the  cerebellum. 

9.  Tumors  of  the  Cerebellum. — Tiiinors  of  the  middle  pe- 
djuiclc  cause  sudden  uncontrollable  movements  of  the  trunk, 
either  toward  the  side  of  the  tumor  or  away  from  it.  Vertigo 
and  nystagmus  are  common.  Symptoms  are  frequently  com- 
plicated by  evidences  of  pontine  disease  proper. 

Tuviors  of  the  middle  lobe  of  the  ccrebelhnn  cause  a  sense 
of  lost  equilibrium  and  obvious  unsteadiness  in  attempting 
to  walk,  or  even  to  stand  (Gowers).  The  patient  has  a  ten- 
dency to  fall ;  there  are  giddiness  and  vomiting. 

Tumors  of  the  cerebellar  hemispheres  produce  no  localizing 
symptoms.  The  usual  unsteadiness  of  gait  is  due  to  press- 
ure upon  the  middle  lobe  (Nothnagel).^ 

Treatment. — In  brain  tumors,  where  any  doubt  exists  as 
to  their  nature,  giv^e  a  course  of  iodid  of  potassium,  and  as 
doubt  is  the  rule,  we  almost  invariably  administer  it.  Give 
at  first  in  small  amounts,  but  rapidly  increase  it  until  heroic 

1  For  full  consideration  of  localizing  symptoms,  see  Gowers  and  Osier,  from 
which  the  above  has  been  condensed. 


568  MODERN  SURGERY. 

doses  are  taken  (loo  or  more  grains  a  day).  Mercury  should 
also  be  given  hypodermatically.  If  iodid  of  potassium  and 
mercury  relieve  the  symptoms,  operation  is  unnecessary, 
although  it  may  be  demanded  later  in  order  to  remove  an 
irritant  scar.  If  antisyphilitic  treatment  fails,  the  question 
of  operation  must  be  considered.  In  many  cases  of  un- 
doubted tumor  excision  for  cure  is  not  attempted  because 
of  the  absence  of  localizing  symptoms  or  because  of  the 
inaccessible  situation  of  the  growth.  Tumors  at  the  base, 
tumors  of  the  pons  and  medulla,  of  the  corpus  callosum, 
of  the  basal  ganglia,  of  the  deeper  parts  of  the  centrum 
ovale,  are  irremovable  (Byrom  Bramwell).  Most  tumors  of 
the  cerebellum  should  not  be  attacked.  In  tumors  which 
are  very  extensive  complete  removal  is  usually  out  of  the 
question.  There  is  no  use  in  removing  secondary  malignant 
tumors.  It  often  happens  that  the  brain  itself  (as  in  syphilis) 
is  so  extensively  diseased,  or  that  other  organs  (as  in  tuber- 
culosis) are  so  involved,  as  to  render  attempts  at  removal 
futile.  Bramwell  tells  us  ^  that  he  has  studied  eighty -two  cases 
of  intracranial  tumors,  and  he  considers  that  in  only  five  of 
them  could  the  tumor  have  been  entirely  removed.  Our 
conclusion  is  that  though  some  tumors  of  the  brain  may  be 
successfully  removed,  extirpation  is  only  to  be  decided  on 
after  careful  study  of  all  the  indications  and  contraindications 
offered  by  the  case.  The  fibromata  constitute  the  best  cases 
for  operation.  In  cases  not  operated  upon  it  may  be  neces- 
sary to  use  the  bromids  for  convulsions  and  morphin  for 
headache.  The  headache  is  often  benefited  by  purgatives, 
courses  of  potassium  iodid,  the  ice-bag  to  the  head,  and  the 
application  of  a  hot  iron  to  the  nape  of  the  neck.  Though 
thorough  extirpation  is  feasible  in  but  few  cases,  operation 
should  often  be  performed  for  palliative  purposes.  Grainger 
Stewart,  Annandale,  Horsley,  Macewen,  and  Keen  have  ad- 
vocated palliative  trephining  in  certain  cases. 

This  procedure  is  of  value  in  diminishing  excessive  intra- 
cranial pressure,  and  thus  relieving  headache  and  decreasing 
the  tendency  to  sudden  death  from  inhibition  of  the  heart 
(Hughlings  Jackson  and  Byrom  Bramwell)  or  respiratory 
failure. 

Palliative  trephining  will  relieve  optic  neuritis  and  thus 
tend  to  prevent  atrophy  and  blindness.  Bramwell  asserts 
this  positively,  and  he  still  believes  that  high  pressure  is  an 
important  element,  though  not  the  only  element  in  neuritis. 

Most  cases  of  tumor  should  be  trephined  for  exploration ; 
1  Edin.  Med.  Jour.,  June,  1894.  - 


DISEASES  AND   INJURIES   OF   THE  HEAD.  569 

in  some  cases  extirpation  may  be  performed ;  in  most  cases  ex- 
tirpation is  impossible,  and  the  surgeon  must  be  content  with 
the  palliative  influence  of  trephining.  A  tumor  of  the  brain 
is  of  necessity  fatal  if  unoperated  upon,  and  trephining  is  not 
a  very  dangerous  operation.  After  palliative  trephining,  make 
an  attempt  to  obtain  prolonged  drainage  of  cerebrospinal 
fluid. 

Operative  Treatment  of  Epilepsy. — The  shock  of 
an  accident  or  a  general  concussion  may  establish  epilepsy, 
especially  in  those  predisposed  by  heredity  or  other  causes. 
Traumatic  epilepsy,  Le  Dentu  tells  us,'  may  be  due  to : 
(i)  bone-fragments  from  skull-fracture;  (2)  outgrowths  of 
bone  due  to  tumor;  (3)  cicatrices  of  meninges  resulting  from- 
laceration  of  membranes  by  bone-fragments ;  (4)  chronic 
meningitis  which  ends  in  sclerosis  of  membranes ;  (5) 
cysts  resulting  from  intracranial  hemorrhage  at  the  point 
of  fracture ;  (6)  arteriovenous  aneurysm.  We  refer  here, 
in  speaking  of  traumatic  epilepsy,  purely  to  the  condition 
when  it  follows  a  head-injury,  and  this  is  the  common 
meaning  of  the  term.  When  epilepsy  has  followed  trau- 
matism and  a  scar  exists  upon  the  scalp,  excise  the  scar, 
especially  if  it  is  tender  or  is  the  seat  of  an  aura.  If,  on 
hfting  the  scalp,  a  depression  of  bone  or  a  disease  of  the 
bone  is  manifest,  trephine  for  exploration,  even  over  a  silent 
area.  Remember  that  epilepsy,  as  shown  by  Sachs,  may 
follow  a  long-forgotten  injury.  Where  the  injury  is  over  a 
known  center,  trephine.  This  operation  is  especially  indi- 
cated when  the  convulsions  begin  in  the  muscles  of  this 
center,  in  which  case  remove  the  center  after  trephining. 
Remove  all  sources  of  peripheral  irritation  (Briggs  reported 
a  case  of  epilepsy  in  which  there  was  distinct  skull-depres- 
sion and  necrosis  of  the  tibia,  but  the  cure  of  the  necrosis 
of  the  tibia  stopped  the  fits).  Trephining  in  epilepsy  may 
disclose  a  cyst,  a  dural  scar,  a  brain-scar,  a  depressed  portion 
of  bone,  or  eburnation  of  bone  from  osteitis  (Keen).  In  ex- 
ploratory operations  for  epilepsy  always  open  the  dura.  If 
epilepsy  arises  notwithstanding  a  primary  trephining,  open 
the  flap,  round  the  bony  edges  with  a  rongeur,  and  cut  out 
the  scar.^ 

These  operations  sometimes  seem  to  cure,  but  so,  occasion- 
ally, does    any  operation.     White  records  ^   ninety  trephin- 

^  La  Presse  Midi  rale,  June  9,  1894. 

^  The  author,  in  Hare's  System  of  Practical  Therapeutics. 
^  "  The  Supposed  Curative  Effects  of  Operations  per  se,"  Annals  of  Surgery, 
August  and  September,  1891. 


570  MODERN  SURGERY. 

ings  in  which,  though  nothing  was  found,  great  relief  fol- 
lowed, and  two  cases  were  apparently  cured ;  he  mentions 
benefit  or  apparent  cure  following  tracheotomy,  ligation  of 
the  carotid,  incision  of  the  scalp,  etc.  The  same  effect  may 
be  obtained  by  a  great  shock,  high  fever,  the  administration 
of  an  anesthetic,  or  an  accident.  The  fact  seems  to  be  that  any- 
operation,  by  means  of  nervous  shock,  may  interrupt  the 
epileptic  habit ;  but  in  ordinary  operations  the  fits  tend  to 
recur,  and  soon  reach  their  old  standard  of  frequency.  In 
the  special  brain-operations  with  excision  of  obvious  lesions 
or  discharging  centers  the  fits  usually  recur,  but  they  will 
rarely  reach  the  old  standard  of  frequency,  and  will  be  more 
amenable  to  medical  treatment.  Bramwell  says  that  when 
traumatism  is  followed  by  epilepsy  and  the  epileptic  discharge 
starts  from  a  cortical  center  which  is  not  beneath  the  scar, 
trephine  first  at  the  seat  of  injury,  and  if  no  lesion  is  met 
with,  trephine  over  the  discharging  center.  In  epilepsy  the 
fits  are  to  be  studied  by  a  competent  observer  (Keen),  and, 
if  focal  epilepsy  or  Jacksonian  epilepsy  exist,  and  treatment 
by  drugs  has  failed,  trephining  is  to  be  performed  over  the 
diseased  center  and  the  explosive  focus  is  to  be  located  by 
an  electric  current  and  removed.  Keen,  Horsley,  Nancrede, 
Macewen,  and  others  practise  this,  but  hope  for  improve- 
ment rather  than  expect  cure.  This  operation  causes  paraly- 
sis, but  the  paralysis  is  rarely  permanent,  except,  perhaps,  of 
the  finer  movements. 

In  non-traumatic  chronic  epilepsy  without  localizing  symp- 
toms trephining  is  not  justifiable  unless  persistent  headache 
calls  for  it  as  a  means  of  relief  from  intracranial  pressure. 
Annandale  has  recently  advised  us  to  consider  experimental 
operation  in  such  cases  when  the  drug-treatment  has  failed 
and  when  the  patient's  condition  seems  hopeless.  He  says 
there  is  no  chance  of  improvement  without  operation,  and 
operation  may  possibly  disclose  a  removable  lesion.^  After 
trephining  for  epilepsy  five  years  should  elapse  without  a 
convulsion  before  cure  is  reasonably  assured;  and  if  con- 
vulsions arise,  they  must  at  once  be  met  by  medical  treat- 
ment. A  man  having  once  had  a  convulsion  may  at  any 
time  have  others ;  hence  he  should  always  be  watched.  It 
is  not  unusual  for  a  few  convulsions  to  occur  soon  after  an 
operation,  and  then  to  cease  for  a  considerable  time.  These 
early  fits  result  from  habit.  Among  the  operative  procedures 
suggested  for  the  treatment  of  epilepsy  may  be  mentioned 
circumcision,  clitoridectomy,  ocular  tenotomy,  ligation  of  the 

^  Edin.  Med.  Jour.,  April,  1894. 


DISEASES  AND   INJURIES   OF  THE  HEAD. 


571 


vertebral  arteries,  removal  of  the  cervical  ganglia  of  the 
sympathetic  (Alexander),  and  the  actual  cautery  to  the 
head  (Fere). 

Operations  on  the  Skull  and  Brain. — Trephining 
(in  a  fracture  of  the  skull). — Shave  the  scalp,  wash  it  with 
ethereal  soap,  then  with  ether,  scrub  with  a  brush  wet 
with  corrosive-sublimate  solution  (i  :  1000),  and  wrap  up 
the  scalp  in  wet  corrosive-sublimate  gauze  (i  :  2000).  The 
instruments  required  are  a  scalpel,  an  Allis  dissector,  hemo- 
static, dissecting-,  and  toothed-forceps,  trephines  of  several 
sizes  (Figs.    175,    176),  a  periosteum-elevator,  a  Hey  saw, 


Fig.  175. — Gait's  conical  trephine. 


Fig.  176. — Crown  trephine. 


rongeur  forceps,  a  bone-elevator,  a  dural  separator,  a  tenac- 
ulum, small  curved  and  large  curved  Hagedorn  needles, 
and  a  needle-holder,  catgut,  fine  silk,  silkworm-gut,  and 
Horsley's  wax.  Provide  a  sand  pillow.  The  patient  is 
anesthetized  unless  he  is  unconscious.  The  patient  lies 
upon  his  back,  the  shoulders  are  a  little  raised,  the  sand 
pillow  is  placed  under  the  neck,  and  his  head  is  turned 
away  from  the  side  to  be  operated  upon.  The  position 
of  the  surgeon  is  such  that  the  patient's  head  is  a  little  to 
his  left.  A  large  semilunar  incision  is  made  with  the  base 
down,  which  incision  goes  through  the  periosteum,  and  the 
flap  is  lifted.  The  bleeding  vessels  of  the  flap  are  caught 
with  forceps.  The  fracture  is  sought  for  and  found.  The 
pin  of  the  trephine  is  projected  beyond  the  crown  and  is  set 
upon  sound  bone,  the  crown  overhanging  the  line  or  edge 
of  the  fracture.  The  surgeon  tries  to  avoid  the  region  of  a 
sinus  or  large  artery.  A  gutter  is  cut  in  the  bone,  the  pin  is 
withdrawn,  and  the  trephining  is  completed.  In  going 
through  the  diploe  bleeding  is  copious.  The  inner  table 
feels  very  dense.  Stop  from  time  to  time,  clean  out  the 
gutter  with  the  dissector,  and  try  the  bone  with  an  elevator 


572  .  MODERN  SURGERY. 

to  see  if  it  is  loose.  When  the  fragment  is  loose  enough, 
pry  it  out  and  hand  it  to  an  assistant,  who  places  it  at  once 
in  a  bowl  of  solution  of  corrosive  sublimate  (i  :  2000),  kept 
warm  by  standing  in  a  basin  of  water  at  105°,  or  who  puts  it 
in  warm  carbolized  towels  or  in  warm  normal  salt  solution. 
The  edges  of  the  opening  are  rounded  with  a  rongeur  and 
the  bone  is  elevated.  Sometimes  it  may  be  necessary  to  re- 
move splinters  and  fragments  of  bone.  The  dura  should  be  ex- 
amined to  see  if  injury  exists,  and  hemorrhage  must  be  stopped. 
Bleeding  from  the  dura  is  arrested  by  passing  a  hgature  of 
silk  or  catgut  under  the  vessel  on  each  side  of  the  wound. 
This  is  effected  by  means  of  a  curved  needle.  Bleeding  from 
the  pia  is  arrested  by  direct  ligation,  or  in  the  same  way  as  is 
bleeding  from  the  dura.  Bleeding  from  the  diploe  is  arrested 
by  the  use  of  Horsley's  wax.  The  wound  is  cleansed,  the 
button  of  bone  is  re-introduced,  or  some  chips  are  cut  from 
the  bone  and  scattered  upon  the  dura.  The  scalp  is  sutured 
with  silkworm-gut  and  horse-hair  or  gauze  drainage  is  em- 
ployed for  a  day  or  two.  Sterilized  gauze  dressings  are  put 
on,  a  rubber-dam  is  laid  over  them,  and  a  gauze  bandage  wet 
with  bichlorid  of  mercury  is  applied. 

Instead  of  the  trephine  some  surgeons  use  the  chisel,  or 
gouge,  and  hammer  to  remove  a  portion  of  the  bone.  Other 
operators  maintain  that  this  procedure  may  cause  concussion, 
and  employ  the  surgical  engine.  After  removing  the  frag- 
ments the  edges  of  the  opening  should  be  smoothed  by  the 
use  of  the  rongeur  forceps. 

Osteoplastic  Resection  of  the  Skull. — Wagner  devised 
the  osteoplastic  method  of  resection.  It  is  employed  for  the  re- 
moval of  tumors  and  the  Gasserian  ganglion,  and  for  explora- 
tion. A  horseshoe  incision  is  made  through  the  scalp  and 
periosteum,  a  groove  corresponding  to  this  incision  is  chiselled 
in  the  bone,  the  bone  is  chiselled  through,  but  is  left  attached 
to  the  scalp.  The  bone  is  then  broken  outward,  the  fracture 
taking  place  at  the  base  of  the  bone-flap.  After  the  opera- 
tion the  bone  which  is  still  adherent  to  the  pericranium  is 
restored  to  its  proper  place.  Some  surgeons  use  the  surgical 
engine  instead  of  the  chisel,  and  others  make  trephine-open- 
ings  and  cut  from  within  outward  by  means  of  the  Gigli 
wire  saw  (Obalinski).  The  osteoplastic  method  of  opening 
the  skull  is  employed  when  a  large  opening  is  necessary, 
as  when  the  operation  is  first  of  all  for  diagnosis.  Krause, 
Keen,  and  others  employ  this  plan  in  operating  to  remove 
the   Gasserian  ganglion. 

Doyen  of  Rheims  has  advocated  the  most  extraordinary 


DISEASES  AND   INJURIES   OF   THE   HEAD.  573 

exploratory  operation.  He  sections  the  vault  of  the  skull 
from  before  backward  near  the  median  line  and  forces 
one  entire  side  outward,  thus  exposing  half  of  the  brain. 
Besides  restoring  a  flap  of  bone  into  position,  or  replacing 
a  button  of  bone,  or  strewing  the  dura  with  bone-fragments, 
other  methods  of  closing  the  opening  have  been  practised. 
For  instance,  heteroplasty  with  decalcified  bone-plates  and 
heteroplasty  with  celluloid  plates  or  other  foreign  material.^ 
Trephining  the  Frontal  Sinus. — This  operation  may  be 
employed  for  inflammation  of  the  lining  membrane  of  the 
sinus  or  for  empyema.  Make  a  vertical  incision  in  the  mid- 
dle of  the  forehead,  starting  one  and  one-half  inches  above 
the  nasion  and  terminating  at  the  root  of  the  nose.  The 
button  of  bone  is  removed  and  the  opening  is  enlarged  if 
necessary.  The  mucous  membrane  is  incised,  the  opening 
into  the  nose  is  found  and  is  dilated,  and  a  drainage-tube  is 
passed  into  the  nose  from  the  sinus,  the  upper  end  being  left 
in  the  sinus.  In  some  severe  cases  Jacobson  advises  us  to 
first  curet  the  sinus,  to  disinfect  it  by  the  use  of  silver  nitrate 
or  chlorid  of  zinc,  and  to  insufflate  an  "  aseptic  powder."  In 
some  cases  resect  the  mucous  membrane.  Some  surgeons 
prefer  an  osteoplastic  resection  to  trephining. 
Trephining  the  Mastoid  (page  575). 

Technique  of  Brain-operations  (after  Horsley  and  Keen). 
— Instruments  as  for  fractured  skull.  In  focal  epilepsy  a  fara- 
dic  battery  is  required.  Always  shave  the  scalp,  and  always 
antisepticize  it.  In  localizations,  mark  out  the  fissure  upon 
the  scalp  with  an  anilin  pencil  or  with  iodin.  Have  the 
patient  semi-recumbent.  Mark  three  points  upon  the  bone 
with  the  center-pin  of  the  trephine  before  incising  the  scalp 
(both  ends  of  the  Rolandic  fissure  and  the  point  at  w^hich 
the  trephine  will  be  applied).  Make  a  semilunar  flap  three 
inches  in  diameter,  with  the  base  below.  Control  bleeding  in 
the  flap  by  forceps  pressure.  The  one  and  a  half  inch  trephine 
should  be  employed,  but  if  a  smaller  trephine  is  used,  the 
opening  must  be  enlarged  with  a  rongeur.  Before  enlarging 
the  opening,  separate  the  dura  from  the  bone  by  a  dural 
separator.  As  a  rule,  open  the  dura  and  examine  the 
brain.  The  dura  is  lifted  by  rat-toothed  forceps  and  is 
opened  with  scissors  along  a  line  a  quarter  of  an  inch  from 
the  bone-edge,  a  broad  pedicle  of  dura  being  left  uncut. 
Hemorrhage  is  arrested  by  pressure  and  hot  water,  or  by 
passing  a  curved  needle  threaded  with  catgut  around  any 
bleeding  vessel.     In  some  cases  packing  must  be  left  in  or 

1  See  Bretans,  in  Detiische  med.  Woch.,  May  17,  1894. 


5  74  MODERN  SUR GER  V. 

forceps  must  be  kept  on.  In  packing,  never  use  more  than 
one  piece  of  gauze,  so  as  to  avoid  leaving  in  a  forgotten 
piece.  Upon  opening  the  dura  cerebrospinal  fluid  flows  out, 
the  stream  being  increased  with  each  expiration.  Absence 
of  pulsation  of  the  brain  points  to  tumor,  and  a  livid  color 
indicates  subcortical  growth.  An  old  laceration  is  brownish. 
If  the  brain  bulges  through  the  opening,  it  means  increased 
pressure  (tumor,  abscess,  effusion  into  the  ventricles,  etc.). 
After  opening  the  dura  employ  no  antiseptics  except  normal 
salt  solution,  especially  when  the  surgeon  intends  using  elec- 
tricity to  locate  a  center.  Remove  any  abnormal  brain-tissue 
which  is  found.  In  operating  for  tumor  the  dura  is  opened  and 
in  some  cases  the  brain  is  incised.  The  tumor  is  turned  out 
by  the  finger,  or,  if  this  is  impossible,  by  the  dry  dissector,  the 
scissors,  or  the  sharp  spoon.  If  the  entire  tumor  cannot  be 
removed,  take  away  as  much  as  possible.  The  removal  of  a 
portion  retards  the  growth  of  the  remainder  (Horsley),  and 
the  trephining,  by  lessening  cerebral  pressure,  relieves  the 
symptoms  and  prolongs  life.  After  removing  a  tumor  arrest 
distinct  points  of  bleeding  with  the  ligature  alone  or  the 
ligature  passed  around  the  vessel  by  means  of  a  needle. 
Pack  the  tumor-cavity  with  gauze  and  bring  the  end  of  the 
plug  out  of  the  wound.  Stitch  the  dura  with  silk  and 
suture  the  scalp  with  silkworm-gut.  In  electrifying  the  brain 
faradism  is  employed  of  a  strength  about  sufficient  to  rnove 
the  thenar  muscles  when  applied  to  them.  The  current  is 
applied  to  the  motor  area  by  the  double  electrode.  A  careful 
observer  watches  the  muscular  movements.  If,  for  instance, 
the  surgeon  wishes  to  remove  the  thumb-center,  he  moves 
the  electrode  from  point  to  point  until  he  obtains  thumb- 
movements.  The  region  is  sHced  away  bit  by  bit  until  the 
current  applied  to  this  zone  no  longer  causes  thumb-move- 
ments. It  will  be  found  impossible  to  remove  only  the  thumb- 
center.  Adjacent  centers  are  sure  to  be  more  or  less  dam- 
aged, and  a  certain  amount  of  paralysis  follows  the  operation. 
If  we  wish  to  tap  the  ventricles.  Keen  directs  that  the  tre- 
phine-opening  be  one  and  one-fourth  inches  behind  the  exter- 
nal auditory  meatus  and  the  same  distance  above  the  base-line 
of  Reid  (Fig.  179,  a).  A  grooved  director  or  metal  tube  is 
passed  into  the  brain  in  the  direction  of  a  point  "  two  and 
one-half  to  three  inches  above  the  opposite  meatus."  The 
normal  ventricle  will  be  entered  at  a  depth  of  two  to  two 
and  one-fourth  inches,  but  the  dilated  ventricle  will  be  entered 
sooner  (Keen).  The  moment  of  entry  is  marked  by  lessened 
resistance  and  a  flow  of  cerebrospinal  fluid.     Drainage  can 


DISEASES  AND   INJURIES   OF   THE   HEAD.  575 

be  maintained  by  introducing  a  rubber  tube.  This  operation 
has  been  employed  in  hydrocephalus.  After  an  aseptic  cere- 
bral operation,  as  a  rule,  do  not  drain  unless  hemorrhage  has 
been  considerable.  In  many  cases  replace  the  bone,  but  not 
when  the  bone  is  diseased,  is  infected,  or  is  very  compact,  or 
if  it  is  desired  to  alter  pressure.  The  dura  is  sutured  by  a 
continuous  silk  suture  (Fig.  177);  the  scalp  is  sutured  by 
interrupted  silkworm-gut  sutures  (Fig.  178). 


(I 

Fig.  177.— Continuous  suture.  FiG.  178.— Interrupted  suture. 

Operation  for  Mastoid  Suppuration. — The  instruments 
required  in  this  operation  are  a  scalpel,  a  gouge,  a  chisel,  a 
mallet,  curets,  a  probe,  a  dissector,  dissecting-  and  hemo- 
static forceps,  and  needles.  Provide  a  sand  bag  to  place 
under  the  neck.  An  incision  is  made  one-quarter  of  an  inch 
posterior  to  the  auricle  and  down  to  the  bone,  and  in  the 
direction  of  the  long  axis  of  the  mastoid.  The  bone  is  bared 
and  examined,  especially  at  a  point  in  the  line  of  the  incision 
which  is  on  a  level  with  the  roof  of  the  meatus  (Fig.  179,  c). 
The  bone  will  usually  be  found  softened.  Gouge  it  away 
and  thus  open  the  mastoid  antrum.  This  bone-opening  is 
within  the  limits  of  Macewen's  suprameatal  triangle,  a  space 
bounded  by  the  posterior  root  of  the  zygoma,  the  posterior 
bony  wall  of  the  meatus,  and  a  line  joining  the  two.  If  the 
mastoid  is  opened  in  this  triangle,  the  antrum  is  entered 
directly  and  there  is  no  chance  of  wounding  the  lateral 
sinus.  If,  in  the  adult,  pus  is  not  found  on  opening  the  mas- 
toid antrum,  gouge  downward  and  backward,  but  with  great 
care,  so  as  to  avoid  the  lateral  sinus.  After  evacuating  the 
pus,  scrape  out  the  cavities  with  the  curet,  enlarge  the 
opening  between  the  mastoid  and  the  middle  ear  with  the 
gouge,  turn  the  head  toward  the  side  operated  upon,  and 
irrigate  the  mastoid  with  corrosive-sublimate  solution 
(i  :  2000) ;  dust  in  iodoform,  pack  with  iodoform  gauze  for  a 
few  days,  and  then  introduce  a  silver  drainage-tube.  Treat 
the  causative  ear  disease.  A.  Marmaduke  Sheild  and 
Macewen  operate  on  inveterate  cases  of  mastoid  disease  as 
follows  :  a  thick  flap  is  raised  behind  the  auricle,  the  flap 
including*  the  orifice  of  any  sinus  and  being  "  left  attached  by 


576 


MODERN  SURGERY. 


its  stalk."  The  auricle  is  "  detached  forward  and  the  soft  parts 
over  the  mastoid  are  turned  backward  by  horizontal  in- 
cision." The  "  lining  membrane  of  the  canal  is  separated 
from  the  bone."  The  mastoid  is  opened  and  dead  bone 
and  caseous  matter  are  removed,  overhanging  edges  are 
chiselled  down,  and  the  posterior  bony  wall  is  gouged  away. 


Fig.  179. — Opening  the  mastoid  antrum  and  the  lateral  sinus  ;  exposure  of  the  temporo- 
sphenoidal  lobe  and  puncture  of  the  descending  horn  of  the  lateral  ventricle  :  a,  temporo- 
sphenoidal  lobe  (descending  cornu  of  lateral  ventricle  is  i  cm.  deeper) ;  b,  inner  surface  of 
periosteum  ;  c,  mastoid  antrum  ;  d,  lateral  sinus  (Kocher). 

The  skin-flap  is  pushed  into  the  cavity  and  is  held  in  place 
with  pads  of  gauze.  The  margins  of  the  flap  may  be  sutured, 
but  this  is  not  necessary.  Macewen  calls  this  procedure 
"  papering  "  the  cavity  with  skin.^ 

If  mastoid  suppuration  has  established  abscess  in  the 
temporosplienoidal  lobe,  trephine  one  and  a  quarter  inches 
behind  and  one  and  a  quarter  inches  above  the  middle  of 
the  external  meatus  (Barker's  point,  Fig.  179,  a),  and  search 

1  Lancet,  Feb.  8,  1896. 


SURGERY  OF  THE   SPINE.  577 

for  pus  as  directed  on  page  562.  If  abscess  of  the  cerebellum 
exists,  trephine  below  the  Hne  of  the  lateral  sinus — that  is, 
belovv^  a  line  running  from  the  inion  to  a  point  on  a  hori- 
zontal line  from  the  roof  of  the  meatus,  one  inch  posterior 
to  the  middle  of  the  meatus.  If  hifcctive  simis-tJirovibosis 
exists,  break  into  the  lateral  sinus  (Fig.  179,  d^  through  the 
mastoid  opening  and  proceed  as  directed  on  page  564. 

Linear  Craniotomy. — Instruments  as  for  any  brain  opera- 
tion, plus,  however,  several  kinds  of  rongeur  forceps.  Make 
a  large  flap.  Trephine  the  skull  a  finger's  breadth  from  the 
sagittal  suture,  and  the  same  distance  back  of  the  coronal 
suture.  Rongeur  the  bone  away  in  a  line  parallel  with  the 
sagittal  suture  up  to  a  point  in  front  of  the  lambdoidal 
suture.  Remove  the  pericranium  which  covered  the  bone 
excised.  Insert  the  dural  separator,  or  pass  it  along  the 
margins.  In  some  cases  an  additional  portion  of  the  bone 
is  removed  over  the  fissure  of  Rolando.  Various  sugges- 
tions have  been  made  as  to  the  direction  and  situation  of 
bone-sections.  Bleeding  is  arrested  and  the  flap  is  closed 
without  drainage. 

Removal  of  Gasserian  Ganglion  (page  533). 

Operation  for  Infective  Sinus-thrombosis  (page  564). 

XXIV.  SURGERY  OF  THE  SPINE. 

Congenital  Deformities. — Spina  bifida,  or  hydrorrha- 
chitis,  is  a  congenital  cystic  tumor  due  to  vertebral  deficiency, 
permitting  protrusion  of  the  contents  of  the  spinal  canal  in 
the  median  line.  The  laminae  or  spines  of  one  vertebra  or 
of  several  vertebrae  may  be  deficient,  most  frequently  in  the 
lumbosacral  region.  Meningocele  is  a  protrusion  of  dura 
mater  and  arachnoid,  the  sac  containing  cerebrospinal  fluid, 
but  no  nerv^es  and  no  cord-substance.  Alcningoviyelocele 
(the  commonest  form)  is  a  protrusion  of  dura  mater  and 
arachnoid,  the  sac  containing  cerebrospinal  fluid,  nerves, 
and  cord-substance.  The  cord  may  spread  upon  the  sac- 
wall  or  it  may  pass  through  the  sac  and  re-enter  the  canal. 
Syringomyelocele  is  great  distention  of  the  central  canal, 
the  sac-w^all  being  formed  of  the  thinned  cord.  A  spina 
bifida  varies  in  size  from  that  of  a  walnut  to  that  of  a 
child's  head ;  it  grows  rapidly  during  the  early  weeks  of 
life ;  it  is  usually  sessile,  but  may  present  where  it  joins  the 
body  a  definite  constriction,  or  even  a  pedicle  ;  the  base  of 
the  sac  is  covered  with  healthy  skin,  and  the  fundus  is 
covered  only  by  thin  epidermis  or  by  the  spinal  membranes 
37 


5/8  MODERN  SURGERY. 

themselves.  Pressure  upon  the  tumor  is  found  to  diminish 
its  size  and  to  increase  the  tension  of  the  anterior  fontanelle, 
and  possibly  to  cause  convulsions  or  stupor.  The  cyst  is 
translucent,  and  the  margins  of  the  bony  aperture  are  dis- 
tinct. Crying,  coughing,  or  pressure  upon  the  anterior 
fontanelle  makes  the  tumor  more  tense.  Spina  bifida  is  apt 
to  be  associated  with  club-foot,  with  hydrocephalus,  and 
with  rectal  or  vesical  paralysis.  Spina  bifida  usually  causes 
death.  A  few  meningoceles  and  a  very  few  meningomyelo- 
celes undergo  spontaneous  cure  by  the  shrinking  of  the  sac. 
Syringomyelocele  is  invariably  fatal.  The  cause  of  death 
may  be  rupture  of  the  sac  or  marasmus. 

Treatment. — Very  small  protrusions  which  grow  slowly 
and  are  covered  with  sound  skin  may  be  treated  by  the  use 
of  a  compress  and  bandage,  by  an  elastic  bandage,  or  by 
applications  of  contractile  collodion.  Some  surgeons  tap 
and  drain  the  sac.  Injection  is  used  by  many.  The  sac 
being  cleaned,  the  child  is  placed  on  its  side  and  a  little 
chloroform  is  given.  A  fine  trocar  is  plunged  obliquely  in 
at  the  side  through  sound  skin,  little  or  no  fluid  being  drawn 
off,  and  3j  of  Morton's  fluid  is  injected  (iodin,  gr.  x ;  iodid 
of  potassium,  gr.  xxx ;  glycerin,  .Ij).  The  trocar  is  with- 
drawn and  the  puncture  is  sealed  with  a  bit  of  gauze  and 
iodoform  collodion.  The  child  is  put  to  bed.  If  the  injec- 
tion proves  successful,  the  sac  shrinks ;  if  the  injection  fails, 
it  may  be  repeated  at  intervals  of  from  seven  to  ten  days 
(Jacobson,  White).  Many  surgeons  prefer  excision  of  the 
sac.  Bayer  treats  it  as  he  would  a  hernia.  Robson,  in 
some  cases,  excises  the  entire  sac  (page  594)- 

Tumors  of  the  Spine. — Among  congenital  tumors  are 
lipomata  and  cysts  (dermoid,  congenital,  sacral,  and  fetal). 
Tubercle,  gumma,  psammoma,  and  fibroma  may  arise  from 
the  cord  or  its  membranes.  Glioma  is  the  most  usual 
growth.  Primary  sarcoma  is  rare.  Angeioma  may  occur. 
Carcinoma  is  never  primary.  A  tumor  rarely  produces  obvi- 
ous symptoms  until  it  is  as  large  as  a  hazel-nut. 

Symptoms  and  Treatment. — Pain,  stiffness  of  the  back, 
areas  of  anesthesia,  and  progressively  advancing  motor 
paralysis  are  symptoms  of  spinal  tumors.  A  tumor  may 
produce  the  symptoms  of  compression-myelitis,  locomotor 
ataxia,  or  myelitis.  In  glioma  there  are  apt  to  be  loss  of 
ability  to  recognize  variations  of  temperature  (or  even  to 
distinguish  between  heat  and  cold),  loss  of  the  sense  of  pain, 
and  paresis  and  atrophy  of  muscles.  Contractures  or  para- 
plegia may  arise.     The  location  of  the  tumor  can  be  inferred 


SURGERY  OF   THE  SPINE.  $79 

by  a  study  of  the  territory  of  paralysis  and  the  zone  of 
sensory  disturbance.  The  tumor  is  always  somewhat  above 
the  upper  limit  of  anesthesia.  In  many  cases  the  diagnosis 
is  impossible.  Gradually  increasing  painful  paraplegia,  with 
pain  in  the  back,  or  with  sensory  paralysis  after  a  time  ap- 
pearing and  ascending  from  the  feet  toward  the  trunk,  points 
to  tumor  as  a  cause.  The  reflexes  are  at  first  increased, 
but  are  finally  lost  from  below  upward.  Spasms  may  de- 
velop, and  lateral  spinal  curvature  may  arise.  If  curvature 
arises,  the  concavity  of  the  curve  will  be  on  the  side  of  the 
tumor.  Growths  outside  the  membranes  produce  partic- 
ularly pain  and  spasm ;  growths  within  the  membranes  pro- 
duce especially  motor  paralysis  and  anesthesia.  If  syphilis  is 
suspected,  give  the  patient  a  course  of  heroic  doses  of  iodid 
of  potassium.  In  a  focal  lesion  not  due  to  dissemination  of 
a  known  malignant  growth  perform  the  operation  of  lamin- 
ectomy to  permit  of  exploration  and  possibly  of  removal. 

Acute  osteomyelitis  of  the  vertebrae  is  a  rare  dis- 
ease ;  it  may  be  associated  with  osteomyeHtis  of  other  bones, 
but  may  occur  alone.  Infections  of  the  viscera  not  unusually 
accompany  it.  Any  part  of  a  vertebra  may  suffer  from  it. 
This  condition  arises  from  cold,  over-exertion,  or  traumatism, 
and  is  more  common  in  the  young  than  in  the  old.  The 
process  may  be  superficial,  or  it  may  involve  the  bone  deeply 
and  widely.  Suppuration  always  occurs;  sequestra  generally 
form;  and  phlebitis  is  a  dangerous  complication.  Any  region 
of  the  spine  may  be  attacked,  but  the  lumbar  region  is  par- 
ticularly liable  to  invasion.  The  situation  of  the  abscess 
varies  with  the  situation  of  the  disease.  If  the  bodies  are 
diseased  the  pus  passes  forward  (retropharyngeal,  mediasti- 
nal, psoas,  or  pelvic  abscess).  If  the  vertebral  arches  suffer, 
the  pus  passes  backward  (lumbar  or  dorsal  abscess).  The 
membranes  of  the  cord,  the  cord  itself,  the  nerves,  and  the 
vertebral  articulations  are  frequently  involved  in  the  process. 
Staphylococci  or  streptococci  may  be  grown  from  the  pus. 

Symptoms. — General  symptoms  are  those  of  osteomyel- 
itis. Local  symptoms  depend  on  the  seat  of  disease.  If  the 
posterior  portion  of  the  column  is  diseased,  there  is  a  hard 
swelling,  which,  in  the  neck,  is  in  the  middle  line ;  in  the  dor- 
sal and  lumbar  regions,  in  the  middle  or  to  the  side ;  and  in 
the  sacral  region,  invariably  to  one  side. 

Rigidity  always  exists.  If  the  vertebral  bodies  are  affected, 
rigidity  is  noted,  the  spine  is  tender,  and  special  symptoms 
arise  dependent  on  the  region  affected  (retropharyngeal  ab- 
scess, etc.).     Occasionally  symptoms  of  meningomyelitis  are 


58o  MODERN  SURGERY. 

noted.  The  constitutional  symptoms  of  sepsis  are  marked, 
the  condition  is  sudden  in  onset,  and  purulent  collections 
diffuse  widely  and  rapidly.  These  points  enable  the  surgeon 
to  make  a  diagnosis  between  osteomyelitis  and  Pott's  disease. 
In  osteomyelitis  angular  deformity  very  rarely  arises,  be- 
cause the  patient  is  recumbent  and  because  hyperostosis  is 
taking  place. 

Treatment. — The  patient  is  kept  recumbent.  His  consti- 
tutional treatment  is  such  as  will  combat  sepsis  (food,  stimu- 
lants, etc.).  A  puriform  area  must  be  incised  and  disinfected. 
If  bone  denuded  of  periosteum  is  found,  it  is  touched  with  a 
solution  of  chlorid  of  zinc  or  the  actual  cautery.  If  a  seques- 
trum exists,  it  is  removed.  A  drainage-tube  is  inserted  and 
dressings  are  applied  (Miiller,  Makins,  Abbot,  and  Chi- 
pault). 

Spinal  Curvatures. — There  are  four  chief  forms  of  spinal 
curvature  :  (i)  lateral  curvature  (the  scoliosis  of  the  older  sur- 
geons) ;  (2)  posterior  curvature  (the  excurvation,  gibbosity, 
or  kyphosis  of  the  older  surgeons) ;  (3)  anterior  curvature 
(the  lordosis  of  the  older  surgeons) ;  and  (4)  angular  curva- 
ture (from  spinal  caries).  The  normal  spine  has  four  curves : 
the  cervical  curve,  the  convexity  of  which  is  forward ;  the  dor- 
sal curve,  the  concavity  of  which  is  backward ;  the  lumbar 
curve,  which  is  convex  anteriorly ;  and  the  pelvic  curve,  which 
is  concave  anteriorly.  The  dorsal  and  the  pelvic  curves,  which 
are  primary,  are  due  to  the  formation  of  the  cavities  of  the 
chest  and  pelvis,  and  depend  upon  the  shape  of  the  bones 
(Treves).  The  cervical  and  lumbar  curves,  which  are  com- 
pensatory, depend  upon  the  shape  of  the  intervertebral 
disks,  and  only  appear  after  birth  when  the  erect  position 
is  assumed. 

Lateral  curvature  (scoliosis)  is  a  lateral  deviation  of  the 
spinal  column,  often  accompanied  with  rotation  of  the  ver- 
tebrae and  associated  with  increase  or  with  diminution  of  the 
normal  curves.  Lateral  curvature  is  predisposed  to  by  weak 
muscles  and  ligaments,  by  the  habitual  assumption  of  strained 
and  unnatural  attitudes,  by  unequal  length  of  the  legs,  and  by 
paralysis  of  one  leg.  This  distortion,  which  is  commonest  in 
girls,  is  apt  to  arise  at  the  age  of  puberty  (it  is  usually  cor- 
rected in  boys  by  outdoor  exercise).  The  bones  are  soft  and 
the  muscles  are  weak,  and  this  condition  is  often  hereditary. 
Rickets  is  very  commonly  associated  with  lateral  curvature. 
Any  condition  of  ill-health  weakens  the  muscles ;  hence  lat- 
eral curvature  may  arise  after  an  acute  sickness  or  in  a  per- 
son who  outgrows  his  strength.     An  empyema  with  adhe- 


SUJiGERY  OF   THE   SPINE.  58 1 

sions,  by  pulling  on  the  chest-wall,  may  produce  a  curvature 
the  concavity  of  which  is  toward  the  diseased  side. 

The  weak  muscles  cease  to  sustain  the  spinal  column,  and 
the  ligaments  stretch,  relax,  or  lengthen.  The  commonest 
curve  is  toward  the  right  in  the  dorsal  region  (be- 
cause most  people  use  the  right  hand  more  than 
the  left).  As  soon  as  a  dorsal  curve  to  the  right 
arises  a  compensatory  lumbar  curve  (Fig.  180) 
takes  place  to  the  left,  thus  enabling  the  patient 
still  to  sit  or  to  stand  erect.  In  almost  all  cases 
the  vertebrse  soon  rotate,  the  bodies  turning  to  the 
convexity  and  the  spines  turning  to  the  concavity 
of  the  curve ;  hence  the  transverse  processes  to- 
ward the  convexity  project.  The  ribs  follow  the 
spinal  rotation ;  the  shoulder  is  elevated  on  the 
side  of  the  convexity,  and  the  hip  on  the  same  side  l JjJ;,  ^l^;~x 
is  raised  (Bowlby).     The  intervertebral  disks  are  curvature    to 

n  1  •  r     1  T        '"^  fight,  and 

apt  to  flatten  out  on  the  concavity  ot  the  curve.    In  compensatory 
very  rare  instances  lateral  curvature  results  from  [""thrief"'^^'^ 
caries  of  a  half  of  one  or  of  several  vertebrje.     In 
a  spinal  tumor  lateral  curvature  may  occur,  the  concavity  of 
the  bend  being  on  the  side  of  the  growth. 

Symptoms. — An  ordinary  case  of  spinal  curvature  from 
weak  muscles  arises  gradually.  Stooping  is  noticed,  and 
after  a  time  pain  is  complained  of  in  the  dorsal  and  lumbar 
regions,  and  weakness  in  the  back  is  detected  by  the  sufferer. 
The  pain  is  made  more  severe  by  sitting  long  in  one  attitude. 
Anemia  is  manifest,  and  walking  is  awkward  and  ungraceful. 
When  the  shoes  and  clothing  are  removed,  and  the  child 
stands  with  its  back  toward  the  surgeon  and  the  feet  sym- 
metrically together,  the  lower  angle  of  the  right  scapula  (in 
a  dorsal  curvature  to  the  right)  is  unduly  prominent  and  is 
elevated  above  the  left ;  the  normal  prominence  of  the  left 
iliac  crest  is  lost ;  the  right  iliac  crest  is  unduly  distinct ;  on 
marking  the  spinous  processes  with  an  anilin  pencil  the  curve 
becomes  manifest ;  tenderness  is  often  developed  on  pressing 
the  spines;  the  normal  dorsal  anteroposterior  curve  is  exag- 
gerated ;  the  abdomen  is  protuberant ;  the  chest  is  flattened ; 
the  neck  juts  forward ;  and  the  breast  on  the  same  side  as  the 
concavity  of  the  curve  is  more  prominent  and  on  a  lower  level 
than  the  other  breast.  Always  observe  if  the  anterior  iliac 
spines  are  on  a  level  or  not,  and  always  measure  the  length 
of  the  legs.  The  patient,  with  the  knees  extended,  bends 
forward  with  the  arms  hanging  loosely :  the  erector  spinae 
muscle  between  the  iliac  crest  and  the  last  rib  is  seen  to  be 


582  MODERN  SURGERY. 

more  prominent  on  the  convexity  of  the  lumbar  curve  than 
on  its  concavity  (Bernard  Roth),  and  the  angles  of  the  ribs 
on  the  side  of  the  convexity  of  the  dorsal  curve  are  on  a 
higher  level  than  are  those  on  its  concavity.  Have  the  child 
assume  what  it  supposes  to  be  an  erect  attitude,  and  let  the 
surgeon  correct  this  into  the  best  possible  position  (Roth), 
and  see  how  long  the  new  position  can  voluntarily  be  main- 
tained. A  large  percentage  of  these  patients  labor  under  pes 
planus.  When  there  is  no  osseous  deformity  (that  is,  when 
the  surgeon  may,  by  manipulation  and  traction,  correct  the 
deformity),  and  when  the  spinal  muscles  are  not  paralyzed, 
the  prognosis  is  good  for  complete  cure.  Roth  states  that 
cases  without  osseous  deformity  can  practically  be  cured  in 
one  month,  but  the  treatment  must  be  continued  for  one  year 
to  prevent  relapse.^  In  cases  of  moderate  osseous  deformity 
the  patient  can  be  improved  vastly  by  three  months'  daily 
treatment  (Roth).  Even  in  severe  cases  of  bony  deformity 
the  pain  may  be  relieved  and  the  deformity  be  modified. 

Treatment. — If  one  leg  is  too  short,  let  the  patient  wear 
a  thick-soled  shoe.  No  treatment  for  weak  muscles  has 
ever  been  devised  so  utterly  irrational  and  absurd  as  the 
prevention  of  all  movement ;  and  neglect  of  all  treatment  for 
lateral  curvature  does  less  harm  than  immobilizing  the  spinal 
muscles  by  braces  and  supports.  The  muscular  nutrition 
in  these  cases  is  to  be  restored,  as  is  muscular  nutrition  in 
any  other  region,  by  scientific  gymnastics,  electricity,  the 
douche,  salt  baths,  frictions,  and  massage.  Bicycles  with 
specially  constructed  seats  are  used  with  advantage  in  some 
cases.  The  mode  of  exercise  to  be  used  should  be  directed 
by  some  one  skilled  in  orthopedics,  and  the  instruction  in 
the  details  must  be  thorough  and  persistent.  Roth's  advice 
is  to  so  re-educate  the  muscular  sense  that  a  patient  can 
again  know  whether  she  is  or  is  not  standing  straight ;  to 
maintain  an  improved  position  in  sitting  and  standing;  to 
use  such  clothing  as  will  not  interfere  with  the  assumption 
of  a  normal  attitude ;  to  enforce  systematic  training  of  the 
muscles  of  the  spine  and  thorax ;  and  to  give  attention  to 
the  general  health.  In  some  cases  where,  in  spite  of  all 
attempts  at  correction,  deformity  increases,  it  may  be  neces- 
sary to  immobilize  in  hope  of  obtaining  ankylosis  and  pre- 
venting further  deformity.  In  those  rare  lateral  curvatures 
due  to  caries  a  supporting  apparatus  must,  of  course,  be 
applied. 

Anteroposterior   curvature   (not  from   spinal  caries    or 

1  Heath's  Dictionary  of  Practical  Surgery. 


Si'RGERY  OF   THE   SPINE.  583 

from  hip-joint  disease)  is  an  increase  of  the  normal  antero- 
posterior curves.     Increase  of  the  dorsal  curve  is  posterior 
curvature,  kyphosis,  or  excurvation  (Fig.  181,  a)  ;  increase  of 
the  lumbar  curve  is  anterior  curvature, 
lordosis,  or   saddle-back   (Fig.   181,  b). 
Both  lordosis  and  kyphosis  are  apt  to 
be  present.     Scoliosis  has  nearly  always 
some    anteroposterior    curvature    asso- 
ciated with   it.     Lordosis    is   apt  to   be 
compensatory,  to  prevent  the  center  of 
gravity  going  too  far  forward.     Lordosis 
is  found  in  pregnant  women  and  in  very 
fat  men.     In  an  old  man  kyphosis  arises 
from  flattening  out  of  the  vertebral  disks 
from    pressure.     Rheumatic    gout    may      ^10.^:8^.. -Kyphosis  (a) 
cause  it.     Anteroposterior  curvature  is 

often  due  to  paralysis  of  the  erector  spinse  mass  (from  infantile 
paralysis).     Pseudo-hypertrophic  paralysis  causes  lordosis. 

Symptoms  ami  Treatment— T\\&  symptoms  of  anteropos- 
terior curvature  are  as  follows :  the  thorax  is  flattened  or 
pigeon-breasted;  the  shoulder-blades  are  widely  separated 
and  the  scapular  angles  project ;  the  abdomen  is  protuberant ; 
the  patient  complains  of  backache  and  soon  tires.  A  recent 
kyphosis  disappears  when  the  patient  lies  upon  his  stomach. 
The  facts  that  the  erector  spinae  muscles  are  soft,  and  that 
pain  is  absent  on  concussion  transmitted  from  the  heels, 
separate  kyphosis  from  caries.  Lordosis  is  unmistakable. 
When  the  spine  is  movable  employ  the  same  plan  of  trcat- 
mait  as  that  in  lateral  curvature,  suiting  the  gymnastics 
to  the  deformity  (Roth).  In  painful  kyphosis  with  partial 
ankylosis  endeavor  to  make  the  ankylosis  complete  to  pre- 
vent pain,  obtaining  this  result  by  applying  a  plaster  jacket 
which  laces  up  and  letting  the  patient  wear  it  for  several 

years.  .  .        ^      ■, 

Angular  curvature  (Spinal  Caries  ;  Spond>4itis  ;  Pott  s 
Disease)  is  usually  due  to  tubercular  caries  of  the  vertebral 
bodies,  and  occurs  particularly  in  children  who  are  predis- 
posed to  tuberculosis,  but  it  may  arise  at  any  age.  Any  por- 
tion of  the  spinal  column  may  be  attacked.  The  dorso- 
lumbar  region  is  most  prone  to  suffer.  The  chief  cause 
is  tuberculosis,  but  syphilis,  secondary  cancer,  and  acute 
myelitis  of  the  vertebrae  are  occasional  causes.  Blows  or 
strains  are  often  exciting  causes.  Angular  curvature  may 
develop  after  an   exanthematous  fever. 

The  cancellous  tissue  of  the  anterior  portion  of  a  verte- 


584  MODERN  SURGERY. 

bral  body  becomes  primarily  carious,  or  the  inflamma- 
tion begins  in  an  intervertebral  disk.  (The  changes  of 
tubercular  osteitis  have  previously  been  set  forth.)  The 
body  of  the  vertebra  and  the  vertebral  disk  are  destroyed, 
and  the  process  extends  to  adjacent  vertebrae.  The  weight 
which  rests  upon  the  spinal  column  causes  softened  bone 
to  crumble,  compresses  the  diseased  vertebrae  and  disks, 
and  produces  angular  deformity  (the  anterior  part  of  the 
spine  formed  by  the  vertebral  bodies  is  shortened,  the  pos- 
terior part  is  not,  and  hence  the  spines  project).  In  some 
cases  the  disease  is  spontaneously  arrested  by  organization 
of  inflammatory  products,  and  ankylosis  (fibrous  or  bony)  in 
deformity  is  Nature's  cure.  In  most  cases,  however,  the  dis- 
ease spreads  and  caseous  pus  is  formed,  which,  according  to 
the  route  it  takes,  causes  lumbar  abscess,  dorsal  abscess, 
psoas  abscess,  or  postpharyngeal  abscess  (page  106).  In 
some  cases  the  spinal  cord  is  compressed,  but  in  most 
cases  it  is  not,  and  even  when  it  is  compressed  paraplegia 
is  rare  and  is  usually  temporary.  Compression  of  the 
cord  may  be  caused  by  the  displaced  vertebrae  or  by  in- 
flammatory material  or  caseous  matter  between  the  bone 
and  dura  mater,  but  is  most  often  due  to  pachymeningitis. 
Caries  of  the  cervical  region  constitutes  a  more  danger- 
ous disease  than  caries  of  either  the  dorsal  or  the  lumbar 
region  (dangerous  pressure  occurs  more  easily).  Death 
may  be  caused  by  exhaustion,  sepsis,  hemorrhage,  amyloid 
disease,  pneumonia,  peritonitis,  pleuritis,  tubercular  dissemi- 
nation, pressure  upon  the  cord,  or  inflammation  of  the  cord 
or  its  membranes. 

Symptoms. — The  first  symptom  of  angular  curvature  is 
pain  in  the  back,  which  is  increased  by  motion,  by  pressure, 
and  by  vertebral  jars.  Neuralgic  pains  pass  into  distant 
parts  (sciatica,  intercostal  neuralgia)  and  are  often  linked 
with  muscular  spasm.  Pain  may  not  appear  until  late  in  the 
progress  of  the  case.  A  chronic  bilateral  pain  in  the  trunk 
or  extremities  is  suggestive  of  Pott's  disease.  "  Chronic  bilat- 
eral belly-aches  in  children  are  almost  diagnostic  "  (Jordan 
Lloyd).  The  pain  of  dorsal  caries  can  be  relieved  by  lifting 
the  shoulders ;  the  pain  of  cervical  caries  by  traction  on  the 
head.  Cramp  in  the  legs  occurs  in  dorsal  and  in  lumbar  caries. 
The  sufferer  from  Pott's  disease,  if  a  child,  grows  tired  easily, 
shows  alteration  of  disposition,  becomes  moody  and  irritable, 
complains  of  vague  pains  in  many  places,  constantly  leans, 
rests,  or  lies  down,  and  walks  with  the  back  rigid,  which 
produces  a  peculiar  gait.     A  painful  spot  is  found  by  press- 


SURGERY  OF  THE   SPINE.  5^5 

ing  upon  the  spines,  and  the  same  spot  is  painful  on  pressing 
the  head  downward  or  upon  jarring  the  entire  spine.     Fara- 
dism  to  the  back  causes  pain.     Spasm  of  the  erector  spinae 
mass   is    detected   (Hilton,   Golding-Eird).      The    presence 
of  the  knuckle  due  to  bending  the  spine  at  an  acute  angle 
is  a  very  important  sign  of  the  disease.     In   many  cases 
angular  deformity  appears  late,  in  some  cases  it  does  not 
appear  at  all.     An  angular  deformity  is  detected  sooner  in 
those  regions  where  the  normal  curves  are  posterior  than 
where   normal   curves    are   anterior   (Jordan    Lloyd).     The 
deformity  appears  early  in  the  dorsal  region,  but  late  in  the 
cervical  and  lumbar   regions.     In   some  rare  cases  lateral 
deformity  occurs.     Rigidity  is  an  early  sign  of  great  impor- 
tance.    It  is  always  present.     Rigidity  is  manifest  very  early 
in   cervical   caries,  tolerably  early  in  lumbar  caries,  late  in 
dorsal  caries.     Lloyd  gives  the  following  practical  rules  to 
enable  us  to  detect  rigidity.^     In  the  cervical  region :  sit  the 
patient  in  a  chair  and  tell  him  to  nod  the  head.     Sdffness  in 
nodding  points  to  occipito-aUoid  disease.     Tell  him  to  look 
far  to  the  right  and  then  far  to  the  left.     Stiffness  of  these 
motions  suggests  atlo-axoid  disease.     Tell  him  to  place  his 
shoulders  against  the  back  of  the  chair  and  carry  his  eyes 
back  along  the  ceiling.     Stiffness  in  this  movement  indicates 
disease  below  the  second  cervical  vertebra.     It  is  practically 
useless  to  examine  the  dorsal  region  of  an  adult  for  rigidity, 
but  such  an  examination  can  be  made  in  a  child.     Place  the 
patient  prone  on  an  adult's  lap,  mark  the  tip  of  each  spinous 
process  with  an  anilin  pencil,  make  the  child  stand  up  straight, 
and  observe  if  any  of  the  marks  have  come  nearer  together. 
If  it  is  seen  that  two  or  more  marks  do  not  approach  each 
other,  there  is  rigidity  which  prevents  approximation.     To 
test  for  rigidity  in  the  lumbar  region  lay  the  naked  patient 
prone  upon  a  couch.     Grasp  the  patient's  ankles  and  raise 
the  pelvis  from  the  couch.     If  the  lumbar  spine  is  flexible, 
the  pelvis  can  be  lifted  without  raising  the  chest  from  the 
bed,  and  the  maneuver  deepens  the  hollow  of  the  loin.     If 
the  lumbar  spine  is  stiff,  the  maneuver  lifts  the  trunk  and 
produces   no    alteration    in   vertical    outline  of  the  lumbar 
spines.     If  a  child  with  Pott's  disease  is  asked  to  pick  up 
something  from  the  ground,  because  of  rigidity  or  pain  on 
movement    he  will   not   bend  the  back,  but  will  bend  the 
knees  or  get  upon  the  knees.     Paralysis  may  exist,  and  it 
is  due  to  pachymeningitis  more  often  than  to  pressure  from 
bone.     Cervical   caries   causes   dyspnea   and  torticollis,  the 

1  Birmingham  Med.  Review,  April,  1897. 


586 


MODERN  SURGERY. 


head  requiring  support  with  the  hand.  Dysphagia  indicates 
abscess.  In  adults  the  first  signs  of  Pott's  disease  to  attract 
attention  are  backache,  neuralgia,  girdle-pain,  cramp,  or  even 
paralysis.  In  sacral  caries  there  is  no  deformity  and  fre- 
quently no  pain.  The  diagnosis  becomes  apparent  when 
bilateral  abscess  is  detected  in  the  buttocks  or  groins 
(Jordan  Lloyd). 

Treatment  of  Caries  of  the  Spine. — When  recent  caries  of 
the  spine  is  active  and  affects  a  child,  when  it  is  accompa- 
nied with  pain  and  fever,  and  when  paralysis  threatens,  insist 
upon  perfect  rest.  Place  the  child  supine  on  a  hard  mattress^ 
and,  if  possible,  take  it,  while  still  in  bed,  out  of  doors  daily. 
Leeches,  blisters,  or  the  hot  iron  over  the  area  of  pain  may 
do  good.  When  the  activity  of  the  process  abates  apply  a 
fixation  apparatus.  In  diseases  at  or  near  the  vertebro- 
occipital  articulation,  as  long  as  dyspnea  persists,  keep  the 
patient  supine  with  a  small  hard  pillow  under  the  nape  of 
the  neck  (Hilton)  and  a  sand-bag  on  each  side  of  the  head 


Fig.  182. — Plaster-of- Paris  jacket  (Sayre). 


Fig.  183. — Plaster-of- Paris  jacket  and 
jury-mast  applied  (Sayre). 


and  neck.  After  several  months  mechanical  support  can  be 
given  by  Furneaux  Jordan's  method.  Jordan  applies  his 
support  as  follows :  the  patient  lies  on  a  flat  hard  table,  his 
arms  are  raised  above  his  head,  and  traction  is  made  upon 
the  head  by  means  of  a  pulley  and  a  weight.  Cotton  pads 
are  placed  over  the  ears,  the  back  of  the  neck,  and  the  clav- 
icles, and  are  held  in  place  by  a  flannel  bandage  applied 
as  a  figure-of-8  of  the  head,  neck,  and  chest.     The  flannel 


SURGERY  OF   THE   SPEXE.  587 

bandage  is  overlaid  with  plaster-of- Paris  bandages.^  In  disease 
of  the  cer\^ical  region  below  the  axis  use  Sayre's  jury-mast 
(Fig.  183).  This  appliance  relieves  the  spine  from  the  weight 
of  the  head  and  acts  admirabh'.  In  many  cases  of  Pott's 
disease  some  fixation  apparatus  is  employed.  The  best  of 
all  fixation  apparatus  is  Sayre's  plaster-of- Paris  jacket  applied 
while  the  patient  is  suspended  (Fig.  182).  The  Sayre  appa- 
ratus applied  in  this  manner  is  used  for  the  treatment  of 
caries  of  the  lumbar  region  and  the  lower  half  of  the  dorsal 
region.  When  all  subjective  signs  cease  substitute  for  Sayre's 
jacket  a  felt  jacket  which  laces  (Golding  Bird).  Caries  of 
the  upper  half  of  the  dorsal  region  is  often  treated  by  a 
Sayre's  jury-mast  (Fig.  183),  but  in  many  cases  the  jury-mast 
will  fail,  and  it  is  necessary  to  place  the  patient  horizontally  in 
"  an  open  cuirass,  fitted  to  the  back  from  occiput  to  sacrum, 
and  combined  with  pulley  extension  to  the  head  and  pelvis."  ^ 

Spinal  abscesses  are  treated  as  indicated  on  page  483. 
Treves  operates  to  remove  the  carious  bone,  making  his 
incision  in  the  back,  but  many  surgeons  do  not  approve 
of  the  operation.  Chipault  and  Calot  have  advocated  forci- 
ble correction  of  the  deformity.  The  patient  is  anesthe- 
tized, and  is  placed  face  down ;  one  assistant  holds  the  feet, 
another  the  head,  another  supports  the  abdomen,  and 
another  the  pelvis.  While  strong  traction  is  made  on  the 
head  and  feet,  the  surgeon  makes  very  forcible  pressure 
on  the  projection.  After  the  correction  of  the  deformity  a 
plaster-of-Paris  support  is  applied  so  as  to  include  the  neck, 
trunk,  and  pelvis.  Plaster-of-Paris  support  is  used  for  at  least 
six  months.  In  some  cases  Calot  resects  the  spines  and 
laminae  of  the  diseased  vertebrae,  and  performs  osteotomy 
of  the  ankylosed  vertebral  bodies.^ 

Some  surgeons  have  warmly  advocated  laminectomy  in 
spinal  caries  paraplegia.  This  operation  is  rarely  necessary, 
but  in  some  few  cases  is  imperatively  demanded.  Many 
cases  recover  from  paraplegia  without  operation — operation 
has  a  ver>'  heav>^  mortality ;  many  are  not  benefited  at  all  by 
it,  but  in  some  cases  it  has  certainly  saved  life  (page  595). 

Laminectomy  should  not  be  undertaken  until  treatment 
by  rest  and  fixation  has  been  applied  for  at  least  one  year 
(Willard). 

Laminectomy  may  be  necessary  in  cervical  caries  to  pre- 
vent asphyxia.     The  operation  enables  the  surgeon  to  re- 

1  See  Children's  Deformities,  by  Walter  Pye. 

^  Jordan  Lloyd,  in  Birmingham  Afedical  Reznnv,  April,  1897. 

^  F.  Calot,  in  Archiv.  Prov.  de  Chirurgie,  Feb.,  1S97. 


588  MODERN  SURGERY.      , 

move  masses  of  inflammatory  material  which  make  pressure 
on  the  cord.  The  dura  should  not  be  opened  unless  there 
is  evidently  trouble  beneath  it,  in  which  case  it  is  incised  and 
any  tubercular  area  removed,  the  dura  being  subsequently 
sutured.  Menards  removes  the  transverse  processes  of  the 
diseased  vertebrae  and  the  heads  and  necks  of  the  associated 
ribs  in  order  to  give  the  surgeon  access  to  the  diseased  ver- 
tebral bodies. 

During  the  course  of  caries  of  the  spine  give  fats,  tonics, 
and  nutritious  food,  and  try  to  get  the  patient  out  often  into 
the  fresh  air.  Sea-air  is  very  beneficial.  When  all  active 
disease  ceases,  and  only  angular  curvature  remains,  use  an 
apparatus  to  combine  extension  with  mechanical  support,  the 
plaster  jacket  being  generally  employed. 

Injuries  of  spinal  ligaments  and  muscles,  which 
may  complicate  more  serious  injuries  or  may  exist  alone,  are 
caused  by  wrenches,  twists,  and  violent  muscular  efforts  (as 
in  lifting).  Railway  accidents  may  be  responsible  for  these 
sprains  and  strains. 

Symptoms. — Injuries  of  the  back,  even  without  cord- 
injury,  are  frequently  Hnked  with  very  deceptive  nervous 
symptoms.  Symptoms  are  often  severe,  but  are  usually 
temporary.  In  some  few  cases  the  symptoms  are  per- 
sistent. Secondary  disease  of  the  cord  is  extremely  rare. 
Any  region  may  be  affected,  but  the  lumbar  is  most  usu- 
ally injured,  and  the  entire  spine  may  suffer.  The  three 
marked  symptoms  are  pain,  tenderness,  and  stiffness  of 
the  back.  At  the  time  of  injury,  and  for  a  time  after,  there 
is  often  marked  shock,  and  hysterical  excitement  is  occa- 
.sionally  observed.  The  cardinal  symptoms  may  arise  very 
soon,  but  may  not  become  severe  for  a  day  or  two.  The 
pain  is  not  acute  when  at  rest,  but  becomes  acute  on  move- 
ment.^ This  pain  is  felt  in  the  back,  and  sometimes  darts 
into  the  extremities.  The  muscles  are  rigid,  the  spasm 
being  due  to  pain.  The  patient  is  very  careful  not  to 
twist  or  bend  the  spine,  because  to  do  so  increases  pain. 
In  a  one-sided  injury  the  rigidity  is  unilateral,  and  this 
symptom  cannot  be  simulated.  Often,  but  by  no  means 
always,  the  region  of  the  back  is  swollen  and  the  skin  is 
discolored.  The  tenderness  is  not  of  the  skin,  but  of  the 
muscles.  Firm  pressure  on  a  real  spot  of  tenderness  causes 
rapid  pulse  (Mannkapf).  The  vertebral  spines  are  regular 
and  are  not  mobile.  There  is  no  distant  paralysis  or 
hyperesthesia  unless  the  cord  is  damaged  (though  in  some 

^  Moullin  on  Sprains. 


SURGERY  OF   THE   SPINE.  589 

rare  cases  the  bladder  and  the  rectum  are  paralyzed  when 
no  cord-lesion  can  be  detected),  and  hyperesthesia  may  exist 
over  the  spines.  Moullin  tells  us  that  the  extremities  feel 
weak  because  they  are  deprived  of  proper  support  on  account 
of  the  immobility  of  the  muscles  of  the  back.  For  the 
same  reason  the  action  of  the  abdominal  muscles  is  inter- 
fered with,  and  the  power  of  micturition  and  of  defecation 
is  impaired  (there  are  constipation  and  difficulty  in  emptying 
the  bladder). 

The  treatment  of  recent  injuries  comprises  rest;  the 
ice-bag  and  leeching  over  the  painful  area ;  in  a  day  or 
two  hot  fomentations,  tincture  of  iodin,  and  inunctions  of 
ichthyol  and  lanolin ;  and,  later,  massage,  douches,  and 
frictions  with  a  stimulating  ointment.  Phenacetin  relieves 
pain,  though  in  some  cases  opium  is  necessary.  The  injury 
is  called  "  railway  spine  "  when  it  is  caused  by  a  railway  acci- 
dent. 

After  the  ivnncdiatc  effects  of  the  accident  subside  trau- 
matic neurasthenia  is  apt  to  arise.  In  this  condition  the 
patient  grows  tired  easily  and  complains  of  pains  and  aches 
in  the  back  and  loins,  interfering  with  or  preventing  work  ; 
paresthesia  and  numbness  exist  in  the  extremities  ;  in  many 
cases  sexual  intercourse  is  impossible  because  of  premature 
ejaculation  or  of  incapacity  for  erection  ;  there  are  dyspepsia, 
eye-strain,  insomnia,  loss  of  memor^^',  rapid  and  irregular 
pulse,  cardiac  palpitation,  and  mental  depression  or  con- 
fusion. The  reflexes  are  usually  exaggerated,  but  they  can 
be  exhausted  more  easily  than  can  the  exaggerated  reflexes 
of  organic  cord  disease  (because  of  irritable  weakness).  Some 
rigidity  and  tenderness  exist  in  the  back,  and  the  skin  over 
this  region  is  often  hyperesthetic.  Attacks  of  retention  of 
urine  may  occur.     Hypochondria  is  not  unusual. 

Treatment  of  Tratiniatic  Neurasthe?iia.  —  Employ  rest, 
tonics,  massage,  douches,  and  frictions  to  the  back.  Secure 
sleep,  and  endeavor  to  bring  about  a  gain  in  weight.  If 
sexual  incapacity  or  seminal  emissions  worry  the  patient, 
dilate  the  urethra  with  steel  bougies. 

Traumatic  hysteria  develops  only  in  those  predisposed  by 
a  neuropathic  hereditar\^  tendency ;  traumatic  neurasthenia 
may  arise  in  anybody.  In  the  first  disease  the  accident  is 
only  the  exciting  cause ;  in  the  second  disorder  it  is  tlie 
cause.  Many  cases  of  so-called  "  railway  spine"  are  really 
examples  of  traumatic  hysteria.  Traumatic  hysteria  and 
neurasthenia  may  be  associated.  Neurasthenia  is  a  con- 
dition of  exhaustion  associated  with  a  number  of  chronic 


590  MODERN  SURGERY. 

disorders  ;  it  forms  a  foundation  on  which  hysteria  loves 
to  build  its  structure.  This  structure  of  hysteria  is  made  up 
of  morbid  impressionability,  hyperesthesia  of  centers,  low- 
ered self-control,  and  sensitiveness  of  the  peripheral  nervous 
system.  The  accident  plays  a  double  part  in  producing  trau- 
matic hysteria  :  first,  by  its  effect  on  the  mind  (psychical  trau- 
matism) ;  second,  by  its  effect  on  the  body,  which  anchors  the 
attention  at  one  point,  and  this  area  of  pain  or  stiffness  often 
serves  as  an  autosuggestion  which  undergoes  morbid  magnif- 
ication when  viewed  through  the  distorting  medium  of  hysteria. 
Erichsen  taught  that  the  symptoms  of  what  he  named  "  rail- 
way spine"  arose  from  inflammation  of  the  cord  and  its  mem- 
branes, a  view  now  abandoned.  A  blow  given  to  a  hysterical 
person  causes  a  feeling  of  numbness,  and  this  negative  sen- 
sation from  local  shock  may  estabhsh  the  idea  of  paralysis, 
or  the  traumatism,  acting  as  a  suggestion,  may  inhibit  motor 
representations  and  destroy  the  normal  ideas  of  motion  and 
feeling  (Charcot  and  Pitre).  Terror  always  causes  a  feeling 
of  loss  of  power  in  the  legs,  and  the  terror  of  the  accident 
may  thus  develop  the  idea  of  paraplegia.  The  site  of  a  trau- 
matism may  localize  symptoms  ;  for  instance,  a  blow  upon 
the  eye  may  cause  amaurosis  or  blepharospasm.  It  is  im- 
portant to  remember  Charcot's  saying  that  a  hysteria,  long 
latent  and  unrecognized,  may  be  awakened  into  obvious 
activity  by  a  blow  or  an  accident.  Pitre  shows  the  same  to 
be  true  of  epilepsy.  A  not  unusual  lesion  is  hysterical  trau- 
matic monoplegia,  not  coming  on  at  once  after  the  accident, 
but  usually  some  days  afterward,  and  presenting  flaccid  mus- 
cles, the  electrical  reactions  and  reflexes  remaining  normal, 
but  the  muscular  sense  being  lost  (Pitre).  The  muscles 
usually  waste.  The  skin  of  the  paralyzed  limb  is  anesthetic 
or  analgesic.  There  may  be  anesthesia  limited  to  a  limb, 
hemianesthesia,  or  general  anesthesia.^  Hysterical  paraly- 
sis is  usually  associated  with  the  permanent  stigmata  of 
hysteria — concentric  contraction  of  the  visual  field,  pharyn- 
geal anesthesia,  convulsive  seizure,  and  hysterogenic  zones 
(Clarke  and  Pitre).  The  permanent  stigmata  may  be  latent. 
Hysterical  phenomena  lack  regularity  of  evolution,  and  they 
may  be  produced,  altered,  or  abolished  by  mental  influences 
or  by  physical  forces  which  produce  no  effect  on  organic 
disease.  In  most  hysterical  conditions  the  general  health  is 
not  profoundly  impaired.^ 

Treatment. — By  moral  means  chiefly.     Gain  the  confidence 
of  the  patient.     In  many  cases  separation  from  family  and 

^  J.  Michell  Clark,  in  Brain.         ^  Read  the  works  of  Thorburn  and  Pitre. 


SURGERY  OF   THE   SPINE.  59 1 

friends  is  necessary-  and  isolation  is  desirable.  The  Weir 
Mitchell  rest-cure  is  the  best  plan  of  treatment,  and  all  its 
details  should  be  carried  out  faithfully. 

Malingering-. — Persons  injured  in  accidents  often  pretend 
to  suffer  from  maladies  which  do  not  exist  in  them.  Some 
get  well  upon  the  rendering  of  a  favorable  verdict  by  a  jury. 
In  any  case  always  examine  carefully,  so  as  to  be  able 
to  exclude  malingering.  Note  the  patient's  behavior  and 
motions  when  his  attention  is  diverted  from  his  disease. 
Meningomyelitis  can  be  excluded  if  there  be  no  spasm  nor 
paralysis,  hyperesthesia,  paresthesia,  or  anesthesia  at  a  dis- 
tance (A.  Pearce  Gould).  If  pain  has  lasted  for  months, 
if  pressure  downward  upon  the  head  or  shoulders  does  not 
increase  pain,  if  the  vertebrae  are  movable  and  there  is  no 
angular  displacement,  exclude  caries.  Gould  states  that 
when  there  are  wasted  muscles,  when  moderate  spine-move- 
ment is  painless,  but  effort  in  bringing  the  body  erect  causes 
pain  in  the  erector  spinae  region,  the  trouble  is  a  strain  of 
the  erector  spinae  muscle.  If  the  muscle  is  not  wasted,  and 
the  pain  is  in  bending  forward  rather  than  in  straightening 
up,  the  vertebral  ligaments  are  the  seat  of  trouble.  Unilateral 
spasm  cannot  be  simulated.  The  administration  of  ether  may 
dispose  of  a  pretended  paralysis. 

Concussion  of  the  Spinal  Cord. — This  term  has  no 
definite  pathological  meaning.  It  is  probable  that  the  condi- 
tion is  one  of  laceration  of  capillaries  and  of  cord-substance. 
The  symptom  is  shock,  with  intense  pallor,  nausea,  often 
vomiting,  and  sometimes  .syncope.  To  this  condition  special 
symptoms  may  be  linked — as  temporary^  paralysis,  a  girdle- 
sensation,  numbness  and  loss  of  power  in  the  Hmbs,  hiccough, 
torticollis,  coarse  tremors,  pains  in  the  back  and  limbs,  areas 
of  anesthesia  and  analgesia — depending  on  the  portion  of 
cord  lacerated. 

Treatment. — The  treatment  in  concussion  of  the  spinal 
cord  is  the  same  as  that  for  sprains.  Traumatic  neurasthenia 
and  hysteria  or  organic  cord-disease  may  follow  this  injury. 

Contusion  of  the  spinal  cord  may  arise  from  a  sprain, 
but  it  is  usually  due  to  extreme  flexion  of  the  spine.  It 
causes  hemorrhage  into  the  gray  matter  of  the  cord  (hema- 
tomyelia).  The  symptoms  are  motor  and  sensor}-  palsy  and 
diminished  reflexes.  Some  cases  recover,  but  others  end  in 
myelitis. 

Wounds  of  the  spinal  cord,  which  are  rare,  are  usually 
fatal.  Wounds  above  the  origin  of  the  phrenic  nerves  cause 
almost  instant  death.     Gunshot-wounds  are  the  most  usual 


592  MODERN  SURGERY. 

form,  the  cord  being  damaged  by  the  bullet  and  by  bone- 
fragments.  A  knife  is  sometimes  thrust  in  between  the 
occiput  and  atlas. 

Compression  of  the  spinal  cord  may  be  due  to  blood 
or  to  lymph.  Compression  from  blood  may  be  due  to  extra- 
medidlmy  hemorrhage  or  to  intramedidlary  hemorrhage, 
Extramedidlary  hemorrhage  causes  sudden  pain  in  the  back, 
the  pain  radiating  from  compressed  nerve-roots ;  hyperes- 
thesia and  paresthesia  in  the  area  of  the  radiated  pain,  spasm 
of  vertebral  muscles  supplied  by  the  compressed  nerves, 
sometimes  of  muscles  whose  nervous  supply  is  below  the 
lesion ;  tremors ;  convulsions ;  retention  of  urine ;  paralytic 
symptoms  following  the  signs  of  irritation,  but  no  absolute 
paralysis  (Mills).  A  girdle-sensation  is  usual.  Intramedul- 
lary hemorrhage  causes  pain,  a  girdle-sensation,  abolition  of 
reflexes,  and  paralysis.  Spasms,  rigidity,  and  paralysis  come 
on  early.  Bed-sores,  retention  of  urine,  and  incontinence  of 
feces  may  occur.  Paralysis  from  hemorrhage  is  gradually 
progressive  from  below  upward  (crawling  paralysis). 

Treatment, — If  paralysis  from  spinal-cord  bleeding  .ex- 
tends rapidly,  and  life  is  endangered  through  the  probable 
involvement  of  a  vital  center,  perform  a  laminectomy,  arrest 
the  hemorrhage,  and  remove  the  clot.  It  is  wise  to  always 
open  the  dura  and  inspect  the  cord.  Extramedullary  hem- 
orrhage may  be  arrested  by  packing.  Intramedullary  hem- 
orrhage may  be  arrested  by  a  suture,  ligature,  or  packing. 
If  an  extramedullary  clot  is  extensive,  it  is  necessary  to  make 
a  second  laminectomy  opening  in  order  to  thoroughly  wash 
it  out.  The  dura  must  be  sutured  and  drainage  is  to  be 
employed.  If  there  is  paraplegia,  complete  anesthesia  of 
the  paralyzed  parts,  and  entire  abolition  of  the  deep  reflexes, 
operation  is  useless  because  the  cord  is  destroyed  (White). 
In  some  cases  with  persistent  paraplegia  the  operation  should 
be  undertaken.  If  operation  is  not  undertaken,  cause  the 
patient  to  lie  upon  his  side  and  give  morphin  hypodermat- 
ically.  If  hemorrhage  continues  in  the  cord  and  if  the  patient 
be  plethoric,  perform  venesection.  Some  surgeons  advise 
hypodermatic  injections  of  ergotin.  To  promote  absorption 
of  the  clot  and  exudate  give  a  combination  of  carbonate  and 
acetate  of  ammonium,  order  pilocarpin,  and  employ  spinal 
galvanism  and  hot  douches  (Bartholow). 

Fractures  and  dislocations  of  the  spine  are  very  rare. 
The  spinal  regions  most  liable  to  injury  are  the  atlo-axial, 
the  cervicodorsal,  and  the  dorsolumbar  (Treves).  A  verte- 
bra may  be  fractured  alone,  but  dislocation  without  fracture,. 


SURGERY  OF  THE   SPINE.  593 

except  in  the  upper  cervical  region,  very  rarely  occurs. 
These  two  lesions,  dislocation  and  fracture,  are  so  often 
associated  that  the  term  fracture-dislocation  is  used  by  many 
surgeons  to  include  them  both.  The  causes  of  fracture  and 
dislocation  are  direct  force  (rarely)  and  indirect  violence 
(commonly).  Fracture-dislocation  from  direct  force  may 
occur  at  any  part  of  the  column,  and  in  this  accident  the 
posterior  vertebral  segments  are  driven  together,  and  the 
cord,  as  a  rule,  escapes  injury.  Fracture-dislocations  from 
indirect  force  most  commonly  happen  in  the  cervical  and 
dorsal  regions.  In  the  cervical  region  reduction  can  usually 
be  secured,  but  in  the  lumbar  region  reduction  is  impossible. 
In  fractures  from  indirect  force  the  cord  generally  suffers. 

Symptoms, — In  fracture-dislocations  much  displacement  is 
rare,  but  some  is  almost  always  recognizable  (irregularity  of 
spines  or  angular  deformity).  In  fractures  there  are  pain 
(which  is  increased  on  motion),  tenderness,  ecchymosis,  and 
motor  and  sensory  paralyses.  Priapism,  cystitis,  and  reten- 
tion of  urine  often  occur.  Horsley  has  pointed  out  that  in 
many  cases  a  paralysis  passes  away  only  to  subsequently 
recur,  the  recurrence  being  due  to  edema  of  the  cord.  In 
some  cases  of  spinal  injury  there  is  temporary  paralysis  due  to 
shock.  Persistent  paralysis  may  be  due  to  laceration  of  cord 
or  compression  of  the  cord  by  bone,  blood-clot,  or  products 
of  inflammation.  In  total  division  of  the  cord  the  deep  re- 
flexes are  abolished,  anesthesia  exists,  and  there  is  vasomotor 
paralysis.  The  extent  of  paralysis  depends  on  the  seat  of 
the  cord-injury.  The  prognosis  depends  on  the  amount  of 
damage  done  to  the  cord.  Fracture-dislocations  in  the  cer- 
vical region  produce  obvious  deformity,  stiffness  of  the  neck, 
and  irregularity  of  the  spines,  and  a  displaced  vertebra  may 
occasionally  be  detected  by  a  finger  in  the  pharynx.  Crepitus 
can  rarely  be  detected  unless  a  spinous  process  is  fractured. 
The  Rontgen  rays  aid  diagnosis. 

Treatment  of  Fracture-dislocations. — When  dislocation 
of  the  body  of  a  vertebra  obviously  exists  attempt  reduc- 
tion by  extension  and  rotation  (White).  The  maneuver 
is  very  dangerous  in  the  cervical  region,  and,  as  deaths 
have  happened,  some  eminent  surgeons  advise  against  re- 
duction when  the  injury  affects  that  region.  In  fracture- 
dislocation  the  traditional  plan  is  to  straighten  the  spine, 
gently  if  possible,  and  to  put  the  patient  upon  his  back 
upon  a  water-bed  or  upon  air-cushions.  In  fractures  in 
the  cervical  region  support  the  head  and  neck  with  sand- 
bags.      Empty  the   bladder   four   times  every  twenty-four 

38 


594  MODERN  SURGERY. 

liours  with  a  soft  catheter,  which  is  kept  strictly  aseptic. 
Take  every  precaution  to  prevent  bed-sores.  Some  sur- 
geons advocate  reduction  of  the  deformity  by  extension  and 
counter-extension,  and  by  the  appHcation  of  a  firmly-fitting 
but  removable  jacket  with  the  suspension  collar  (as  used  in 
Pott's  disease).  The  head  of  the  bed  is  raised  and  the  collar 
is  fastened  to  it.  Every  day  extend  gently  from  the  shoul- 
ders in  dorsolumbar  fracture,  and  from  the  chin  and  occi- 
put in  cervical  fractures.  Extension  may  be  maintained 
permanently  until  cure.  White  says  laminectomy  should 
be  performed  for  fracture  or  for  dislocation  when  there  is 
obvious  depression  of  the  vertebral  arches  ;  in  all  cases  of 
pressure  upon  the  cauda  equina ;  when  there  are  character- 
istic symptoms  of  spinal  hemorrhage ;  and  in  some  cases 
where  rapid  degeneration  becomes  manifest.  Surgeons,  as  a 
rule,  agree  that  operation  will  be  useless  when  there  are  com- 
plete persistent  anesthesia  and  entire  loss  of  reflexes,  because 
these  symptoms  indicate  that  total  division  of  the  cord  has 
taken  place.  It  is  useless  to  operate  for  fracture-dislocation 
of  the  atlas  or  axis.  In  ordinary  cases  treat  by  extension 
for  six  or  eight  weeks,  and  then  operate  if  the  case  is  not 
improving.  In  hemorrhagic  cases,  or  cases  with  marked 
depression  of  the  arches,  operate  early.  If  signs  of  degen- 
eration begin  within  six  or  eight  weeks,  operate  at  once. 
*'  In  compound  fractures,  in  injuries  of  the  laminae  and  spinous 
processes  without  a  complete  crush  of  the  cord,  when  symp- 
toms are  due  to  hemorrhage,  when  pachymeningitis  arises, 
if  the  Cauda  equina  is  compressed,  operate"  (Thorburn). 

Operations  on  the  Spine. — Operations  for  Spina 
Bifida. — Mayo  Robson  maintains^  that  operation  is  not  de- 
manded when  the  sac  is  of  small  size  and  is  well  protected 
by  sound  integument ;  that  operation  is  improper  when  a 
large  portion  of  the  column  is  fissured,  or  when  paraplegia 
or  hydrocephalus  exists ;  that  operation  is  only  advisable 
in  meningocele,  in  cases  where  integument  is  thin  and  trans- 
lucent, in  cases  where  the  cord  is  flattened  out,  or  the  nerves 
are  fused.  Robson  has  closed  the  osseous  defect  by  trans- 
planting periosteum. 

Instruments  Required.  —  Scalpels,  dissecting-  and  hemo- 
static forceps,  scissors,  rongeur  forceps,  dural  separator, 
Hagedorn  needles  and  needle-holder,  silk,  silkworm-gut  or 
-catgut. 

Operation. — Surround  the  sac  by  elliptical  incisions.  Find 
the  neck  of  the  sac,  and  if  it  contains  no  visible  nerves  ligate 

^  Annals  of  Surgery,  vol.  xxii.,  No.  i. 


SURGERY  OF   THE  SPINE.  595 

it  and  cut  off  the  protrusion.  Push  the  stump  into  the  canal. 
Freshen  the  bone-margins  and  spring  a  piece  of  celluloid 
beneath  them  to  close  the  gap  (Park).  Suture  over  the 
stump  with  small  sutures  of  catgut.' 

Treves's  Operation  for  Vertebral  Caries  (page  483). 

Laminectomy. — The  instruments  required  in  laminectomy 
are  dissecting-,  rat-toothed,  and  hemostatic  forceps;  scalpels; 
bone-cutting  forceps ;  rongeur  forceps ;  a  dry  dissector ;  a 
periosteum  -  elevator  ;  sequestrum  -  forceps  ;  small  scissors, 
straight  and  curved  on  the  flat;  a  chisel  and  mallet;  re- 
tractors ;  blunt  hooks ;  a  probe ;  tenaculum-forceps ;  a 
spoon-curet ;  a  sand -pillow;  fine  needles,  curved  and 
straight,  large  needles,  and  a  needle-holder. 

In  the  operation  of  laminectomy  the  patient  lies  prone 
and  a  sand-pillow  is  placed  under  the  lower  ribs.  Make  an 
incision  down  the  vertebral  spines,  the  middle  of  the  incision 
corresponding  to  the  seat  of  fracture.  The  sides  of  the 
spinous  process  and  the  laminae  are  cleared.  The  perios- 
teum is  incised  in  the  angle  between  the  laminae  and  spines, 
and  it  is  lifted  away  from  the  arch.  The  spinous  processes 
are  cut  off  with  forceps  close  to  their  bases,  the  laminae  are 
removed  on  each  side  with  the  rongeur,  and  the  dura  is 
exposed.  In  some  cases  the  fragments  will  be  found  on 
exposing  the  vertebra,  or  the  blood-clot  will  be  seen  between 
the  dura  and  the  bone ;  in  other  cases  the  dura  must  be 
opened  with  scissors  vertically  in  the  middle  line  while  it  is 
grasped  with  rat-toothed  forceps.  After  reaching  and  re- 
moving the  compressing  cause,  or  after  failing  to  find  or 
remove  it,  close  the  dura  with  catgut,  drain  the  length  of  the 
wound  with  a  tube,  stitch  the  superficial  parts  with  silkworm- 
gut,  and  dress  antiseptically.^ 

Puncture  of  the  spinal  meninges,  or  lumbar  puncture, 
was  devised  by  Quincke,  and  has  been  carefully  tried  by 
many  surgeons  (Furbringer,  Naunyn,  and  others).  It  is 
employed  as  a  means  of  diminishing  cerebral  pressure  in 
hydrocephalus,  cerebral  tumor,  uremia,  and  tubercular  men- 
ingitis. It  has  proved  of  little  therapeutic  value.  In  some 
cases  the  examination  of  the  fluid  has  been  of  diagnostic 
value.  Stadelmann  has  reported  37  cases  in  which  tubercle 
bacilli  were  found  in  the  fluid.^  Turbidity  of  the  fluid  indi- 
cates the  existence  of  meningitis.    The  back  is  sterilized  ;  the 

^  A  full  consideration  of  the  various  plans  of  operating  will  be  found  in  an 
article  by  Marcy.  in  Annals  of  Surgery,  March.  1895. 

2  See  J.  W.  White's  description  in  the  Annals  of  Surgery,  July,  1889. 
^Berliner  klinische  IVochenschrift,  July  8,  1895. 


596  MODERN  SURGERY. 

patient  may  lie  prone,  with  a  pillow  under  the  belly,  or  may 
sit  in  a  chair,  with  the  body  bent  forward ;  no  anesthetic  is 
required.  A  Pravaz  syringe  is  employed,  and  the  point  is  in- 
serted at  the  under  surface  of  a  spinous  process.  In  some 
cases  but  £1  few  drops  of  fluid  will  be  obtained,  in  other 
cases  many  ounces  can  be  removed. 

XXV.  SURGERY  OF  THE  RESPIRATORY  ORGANS. 

I.   Diseases  and  Injuries  of  the  Nose  and  Antrum. 

Foreign  bodies  in  the  nose  are  usually  introduced 
through  the  anterior  nares,  but  in  rare  instances  they  enter 
by  way  of  the  posterior  nares.  Small  particles  are  often 
expelled  spontaneously ;  larger  pieces  gather  mucus  and 
become  fixed.     Some  materials  swell  after  lodgement. 

Treatment. — Illuminate  the  nostril,  and,  if  the  foreign 
body  can  be  seen,  insert  a  hook  back  of  it  and  effect  its 
removal  by  means  of  forceps.  In  many  cases  anesthesia  is 
required.  Some  foreign  bodies  require  to  be  pushed  back  into 
the  nasopharynx.  Occasionally  expulsion  may  be  effected  by 
inserting  a  rubber  tube  into  the  unblocked  nostril  and  telUng 
the  patient  to  blow  forcibly  through  the  tube.  In  serious  cases 
a  specialist  should  be  summoned  to  remove  a  portion  of  the 
turbinated  bone  or  to  perform  whatever  operation  he  thinks 
best. 

Inflammation  and  Abscess  of  the  Antrum  of 
Highmore  (Maxillary  Antrum). — The  source  of  this 
disease  may  be  inflammation  of  the  nose  or  periostitis  around 
the  roots  of  the  teeth.  In  some  cases  the  opening  into  the 
nose  is  patent ;  in  other  cases  it  is  partly  or  completely  blocked. 
Caries  and  necrosis  may  arise.  The  symptoms  are  pain, 
edematous  swelhng  of  the  face,  and  thinning  of  the  bone  so 
that  it  may  crepitate  under  pressure.  When  pus  has  formed 
certain  positions  of  the  head  will  cause  a  purulent  flow  from 
the  nose,  and  if  a  speculum  is  inserted  pus  may  be  seen  as  it 
flows  into  the  nose.  The  opening  of  the  maxillary  antrum 
into  the  nose  is  at  the  summit  of  the  cavity ;  hence  the  an- 
trum drains  when  the  head  is  inverted.  The  ethmoidal  cells 
and  frontal  sinus  drain  best  when  the  patient  is  upright.  Wipe 
the  interior  of  the  nose  and  place  the  patient  with  his  head 
between  his  knees.  If  the  nostril  fills  with  pus,  it  comes  from 
the  antrum  (Cobb).  In  severe  cases  the  jaw  expands,  the  eye 
protrudes,  and  great  tenderness  of  the  alveolus  exists.  Per- 
cussion exhibits  a  dull  note.  In  making  a  diagnosis  it  is  well 
to  take  the  patient  into  a  dark  room,  insert  an  electric  Hght  into 


SURGERY  OF   THE   RESPIRATORY  ORGANS.  S97 

the  mouth  and  note  the  diminution  of  light-transmission  on 
the  diseased  side  as  contrasted  with  the  sound  side  Trans- 
illumination may  be  easily  practised  by  the  use  of  a  cautery 
electrode,  protected  by  a  small  glass  vial.  Any  cautery  bat- 
tery may  be  employed  (plan  suggested  by  Ohls).  Explora- 
tory puncture  will  settle  a  doubtful  diagnosis.  This  may  be 
by  way  of  the  lower  meatus,  the  canine  fossa,  or  the  alveolar 
process.^ 

Treatment. — Before  pus  forms,  order  the  use  of  hot  fomen- 
tations, and  remove  any  diseased  teeth.  When  pus  has  formed 
evacuate  it  at  once.  Before  performing  a  severe  operation  try 
the  effect  of  opening  into  the  antrum  from  the  nose,  by  means 
of  Krause's  trocar,  followed  by  insufflation  of  iodoform.  If 
this  procedure  fails,  other  means  may  be  employed.  If 
the  disease  arises  from  a  carious  tooth,  pull  the  tooth  and 
push  a  trocar  through  its  socket  into  the  antrum.  If  the  teeth 
are  sound,  bore  a  hole  with  a  large  gimlet  or  with  a  bone- 
drill  above  the  root  of  the  second  bicuspid  tooth  and  one 
inch  above  the  edge  of  the  gum.  A  counter-opening  should 
be  made  into  the  inferior  nasal  meatus.  A  drainage-tube  is 
pulled  from  the  first  opening  into  the  nose  and  is  allowed  to 
protrude  from  the  nostril.  Irrigate  daily  with  peroxid  of 
hydrogen.  In  three  or  four  days  discontinue  through-and- 
through  drainage,  but  prevent  the  first  opening  from  closing 
until  the  discharge  ceases  to  be  purulent.  In  severe  cases 
make  a  free  incision  through  the  canine  fossa  by  means  of  a 
chisel. 

Distention  and  Abscess  of  the  Frontal  Sinus.— 
The  usual  cause  is  an  injury  which  may  long  antedate  the 
symptoms.  This  injury  causes  or  leads  to  blocking  of  the 
infundibulum  ;  secretion  accumulates  and  distends  the  sinus  ; 
and  in  some  cases  pus  forms.  In  many  cases  the  fluid  slowly 
accumulates,  and  it  requires  )-ears  to  produce  marked  symp- 
toms. In  other  cases  infection  takes  place,  and  the  symptoms 
are  positive  and  violent.  If  the  outlet  into  the  nose  is  not 
permanently  blocked,  the  fluid  may  discharge  itself  from  time 
to  time.  In  the  chronic  cases  there  is  rarely  much  pain.  The 
chief  sign  is  a  swelling  of  the  inner  or  upper  part  of  the  orbit, 
which  swelling  progressively  increases  in  size  and  displaces 
the  eye.  If  at  any  time  acute  symptoms  supervene,  there 
will  be  pulsatile  pain,  discoloration,  and  tenderness. 

Treatment. — In  some  cases  it  is  possible  to  pass  a  trocar 
upward  from  the  nose  into  the  sinus,  and  so  drain  and  irri- 
gate.    In  most  cases  an  incision  should  be  made  through  the 

1  Cobb,  in  Boston  Med.  and  Surg.  Jour.,  May  7,  1896. 


598  MODERN  SURGERY. 

soft  parts,  and  the  sinus  opened  by  a  trephine  or  chisel.  After 
the  sinus  has  been  opened  it  must  be  curetted,  the  opening 
into  the  meatus  should  be  restored  and  enlarged,  and  a 
drainage-tube  is  to  be  passed  from  the  forehead  incision  into 
the  nostril.  Some  surgeons  open  the  sinus  by  making  an 
osteoplastic  flap. 

2.   Diseases  and  Injuries  of  the  Larynx  and  Trachea. 

Bdema  of  the  lyarynx  (Edema  of  the  Glottis). — The 
causes  of  edema  of  the  larynx  are — acute  laryngitis  ;  chronic 
diseases,  such  as  tuberculosis,  malignant  disease,  or  syphilis ; 
inflammatory  disorders,  such  as  diphtheria  and  erysipelas ; 
acute  infectious  diseases;  Bright's  disease ;  aneurysm;  whoop- 
ing-cough ;  pneumonia ;  quinsy ;  wounds  of  the  larynx ; 
wounds  of  the  neck ;  scalds  and  burns  of  the  larynx,  and 
the  inhalation  of  irritating  vapors,  such  as  those  of  ammonia 
and  sulphur.  The  symptoms  are  sudden  and  rapidly  increas- 
ing dyspnea,  respiratory  stridor,  huskiness  of  the  voice,  and 
finally  aphonia.  The  swollen  epiglottis  may  be  felt  with  the 
finger  and  may  be  seen  with  a  mirror. 

Treatment. — In  cases  in  which  edema  of  the  larynx  is 
not  excessively  acute  make  multiple  punctures  into  the  epi- 
glottis and  favor  bleeding  by  the  inhalation  of  steam.  In 
severe  cases  perform  intubation  or  tracheotomy. 

Wounds  and  Injuries  of  the  I^arynx. — The  larynx 
may  be  injured  internally  by  foreign  bodies,  and  externally 
by  blows  and  cuts.  A  condition  often  met  with  is  cut  throat, 
the  result  usually  of  a  suicidal  attempt  on  the  part  of  the 
patient  or  a  homicidal  effort  on  the  part  of  an  assailant. 
The  cut  of  the  suicide  is  usually  in  front ;  it  misses  the  great 
vessels,  but  divides  the  cricothyroid  or  thyrohyoid  membrane. 
The  epiglottis  may  be  incised,  or  even  be  cut  off.  If  a  large 
vessel  is  cut,  death  rapidly  occurs.  The  immediate  dangers 
of  cut  throat  are  hemorrhage,  suffocation  by  blood,  entrance 
of  air  into  veins,  and  suffocation  by  displacement  of  parts. 
The  secondary  dangers  are  pneumonia,  infection  and  sepsis, 
exhaustion,  and  secondary  hemorrhage.  The  remote  dangers 
are  stricture  and  fistula  (Keetley). 

Treatment. — In  wounds  of  the  throat  arrest  hemorrhage, 
remove  clots  from  the  larynx  and  trachea,  bring  about  reac- 
tion, asepticize  the  parts  as  well  as  possible,  suture  the  deeper 
structures  with  silver  wire,  cato-ut,  or  kangaroo-tendon,  and 
the  superficial  parts  with  silkworm-gut,  dress  antiseptically, 
and  place  a  bandage  around  the  head  and  chest  so  as  to 


SURGERY  OF   THE   RESPIRATORY  ORGANS.  599 

pull  the  chin  toward  the  sternum.  If  laryngeal  breathing 
is  much  interfered  with,  perform  tracheotomy.  Feed  the 
patient  through  a  tube  until  union  has  well  advanced.  The 
old  method  of  leaving  the  wound  open  is  to  be  condemned. 
When  sutures  are  used  primary  union  may  be  obtained. 
This  fact  was  proved  by  Henry  Morris. 

Foreign  Bodies  in  the  Air-passages. — The  lodge- 
ment of  foreign  bodies  in  the  air-passages  is  a  frequent  acci- 
dent. Small  solid  bodies  are  usually  expelled  by  coughing. 
Liquids  and  solids  rarely  pass  beyond  the  larynx  (except  in 
laryngeal  disease  or  palsy,  wounds  of  the  floor  of  the  mouth, 
cut  throat,  and  in  people  unconscious  or  very  drunk).  In 
vomitinsT  during  or  after  the  administration  of  an  anesthetic, 
or  in  the  vomiting  of  drunkards,  the  vomited  matter  may  find 
its  way  into  the  larynx  or  lungs.  There  is  great  danger  of 
this  accident  in  an  operation  upon  a  patient  with  intestinal  ob- 
struction who  has  stercoraceous  vomiting.  In  most  instances 
of  foreign  bodies  lodged  in  the  air-passages  it  will  be  found 
that  the  object  was  being  held  in  the  mouth  when  a  sudden 
deep  inspiration  was  taken  (often  from  laughter).  The  symp- 
toms are  immediate,  due  to  obstruction  by  the  body  and  to 
spasm,  and  secondary,  due  to  the  situation  of  the  body  and 
the  changes  it  undergoes  or  induces. 

Lodgement  in  the  pharynx  causes  violent  dyspnea.  The 
body  can  be  seen  or  felt. 

Lodgement  in  the  Larynx. — In  a  severe  case  the  patient 
fights  madly  for  air  ;  his  face  becomes  livid  and  cyanotic  ;  his 
veins  stand  out  prominently  ;  speech  is  impossible,  though  he 
may  make  noises  and  utter  harsh  cries  ;  violent  coughing  be- 
gins, and  then  vomiting ;  he  tries  to  force  a  finger  down  his 
throat  and  clutches  at  his  neck  ;  sweat  pours  from  him  ;  he 
feels  a  sense  of  impending  dissolution,  and  he  falls  down  un- 
conscious, with  incontinence  of  feces  and  urine.^  In  a  less 
severe  case  violent  dyspnea  gradually  departs  and  the  patient 
lies  exhausted ;  but  dyspnea  and  cough  are  liable  to  recur 
suddenly  at  any  time  because  of  spasm,  and  they  may  be 
induced  by  a  change  of  position.  These  attacks  of  fierce 
spasmodic  cough  are  not  at  first  linked  with  expectoration, 
but  after  inflammation  begins  there  is  a  profuse  and  often 
bloody  expectoration.  Inflammation  follows  more  rapidly 
the  lodgement  of  a  sharp  or  irregular  body  than  it  does  that 
of  a  round  or  smooth  body.  Inflammation  is  apt  to  produce 
edema  of  the  glottis,  bronchopneumonia,  or  ulceration  and 
necrosis  of  the  larynx.      Any  foreign  body  in   the  larynx 

^  See  MouUin's  graphic  description  in  his  Treatise  on  Surgery. 


600  MODERN  SURGERY. 

may  at  any  moment  produce  spasmodic  dyspnea,  and  it  is 
always  very  liable  to  cause  edema  of  the  glottis.  The  body 
if  bony  or  metallic  can  be  detected  by  the  X-rays. 

Lodgement  in  the  Trachea. — The  immediate  symptoms  of  a 
foreign  body  in  the  trachea  depend  on  the  shape  and  weight 
of  the  body,  and  whether  it  becomes  fixed  in  the  mucous 
membrane  or  moves  to  and  fro  with  the  air-current.  A 
smooth,  heavy  body  falls  to  the  tracheal  bifurcation,  and,  if 
it  does  not  enter  a  bronchus,  moves  with  every  breath,  and 
by  its  movement  causes  violent  laryngeal  spasm,  cough,  and 
whooping  inspiration  without  aphonia.  The  patient  is  often 
conscious  of  the  movements  of  the  foreign  body,  and  the 
surgeon  may  detect  them  with  the  stethoscope.  The  for- 
eign body  may  be  found  with  the  Rontgen  rays.  A  foreign 
body  in  the  trachea  is  liable  to  cause  death  by  dyspnea,  or 
it  may  ascend  so  as  to  be  caught  in  the  larynx,  or  may  even 
be  expelled.  Irregular  or  sharp  bodies  lodge  in  the  mucous 
membrane,  produce  inflammation,  frequent  cough,  and  ex- 
pectoration, and  finally  lead  to  ulceration.  Bodies  which 
swell  up  from  heat  and  moisture  tend  to  lodge  and  to  become 
fixed  (seeds  may  sprout). 

Lodgement  in  a  Bronchus. — Foreign  bodies  in  the  bronchi 
usually  lodge  in  the  right  bronchus.  When  a  small  lung- 
area  is  obstructed  the  obstructed  side  shows  diminished 
respiratory  movement  and  murmur  with  occasional  whistling 
sounds  and  large  moist  rales  ;  the  percussion-note  is  normal. 
When  an  entire  lobe  is  obstructed  all  respiratory  sounds 
are  absent  over  it,  and  over  the  unobstructed  lung  respira- 
tion is  exaggerated ;  the  percussion-note  over  the  obstructed 
area  is  at  first  resonant,  but  becomes  dull.  The  X-rays  will 
enable  the  surgeon  to  detect  some  foreign  bodies  in  a  bron- 
chus. Lodgement  in  a  bronchus  may  cause  bronchopneu- 
monia, abscess,  hemorrhage,  and  even  gangrene. 

Treatment. — If  a  foreign  body  lodges  in  the  pharynx,  try 
to  pull  it  forward ;  if  this  fails,  push  it  back  into  the  esoph- 
agus. In  lodgement  in  the  larynx  or  below,  if  the  symptoms 
are  very  urgent,  at  once  perform  a  quick  laryngotomy.  If 
the  symptoms  are  not  so  urgent,  get  a  complete  history  of 
the  accident  and  find  out  the  nature  of  the  foreign  body.  Be 
sure  a  foreign  body  is  retained  in  the  respiratory  tract,  and  de- 
termine what  its  situation  may  be.  Often  a  laryngologist  can 
remove  a  foreign  body  from  the  larynx  by  means  of  forceps, 
a  mirror  and  lamp  being  used  for  illumination.  The  fauces 
and  upper  portion  of  the  larynx  should  have  cocain  applied 
to  them  to  lessen  pain  and  spasm.     If  the  surgeon  fails  in 


SURGERY  OF   THE   RESPIRATORY  ORGANS.  6oi 

extraction  by  forceps,  and  laryngotomy  has  been  performed, 
continue  the  search  through  the  opening  in  the  cricothyroid 
membrane ;  if  laryngotomy  has  not  been  performed,  let  it  be 
done  in  the  form  known  as  tJiyrotomy  (a  vertical  incision 
between  the  alae  of  the  thyroid  cartilage,  and  the  separation 
of  these  alae  to  permit  of  exploration).  After  a  thyrotomy 
suture  the  perichondrium  with  catgut.  If  the  foreign  body 
is  in  the  trachea  or  in  a  bronchus,  perform  tracheotomy : 
this  prevents  suffocation  from  laryngeal  spasm  or  edema. 
The  foreign  body  may  be  expelled ;  if  it  is  not  expelled, 
search  the  trachea  and  bronchi  with  Gross's  forceps,  with 
probes,  with  hooks,  or  with  the  finger.  If  the  foreign  body 
cannot  be  found,  put  the  patient  to  bed,  and  maintain  a  moist 
atmosphere  in  the  room.  As  a  rule,  when  the  foreign  body  is 
not  found  insert  a  tube.  If  the  foreign  body  be  extracted  do 
not  insert  a  tube  (unless  edema  of  the  glottis  exists  or  is  likely 
to  come  on),  do  not  suture  the  wound,  but  cover  it  with 
moist  gauze  and  let  it  heal  by  granulation.  Morphin  and 
sedative  cough-mixtures  are  given.  Gross  says  that  even 
when  a  foreign  body  has  long  been  retained  an  operation 
should  be  performed  so  long  as  the  air-passages  are  not 
seriously  diseased.  What  shall  be  done  when  a  foreign 
body  is  lodged  in  a  bronchus  and  we  are  unable  to  extract 
it  through  a  tracheotomy  w^ound  ?  True  said  if  "  the  patient 
is  in  danger  of  death  "  go  through  the  chest-wall  and  at- 
tempt to  remove  the  body.  He  said  this  with  a  full  knowl- 
edge of  the  difficulty  of  locating  the  body.  This  difficulty 
has  been  partly  overcome  by  the  X-rays,  and  it  seems  more 
certainly  our  duty  now^  to  pursue  this  plan  than  it  was  a 
short  time  ago.  Some  surgeons  advocate  incision  from 
behind.^  It  is  possible  to  reach  the  bronchus,  but  many 
surgeons  believe  that  advances  in  technique  will  be  necessary 
before  we  can  hope  to  save  a  patient  by  opening  a  bronchus 
and  removing  a  foreign  body.  Paget  disbelieves  in  any  direct 
incision. 

3.  Operations  on  the  Larynx  and  Trachea. 

Tracheotomy. — The  instruments  required  in  this  oper- 
ation are  the  scalpel,  dissecting-forceps,  a  dry  dissector, 
hemostatic  forceps,  scissors,  a  tenaculum,  aneurysm-needle, 
tubes,  tapes,  Paquelin  cautery,  needles,  needle-holder,  a 
mouth-gag,  tongue-forceps,  foreign-body  forceps,  retractors, 
and,  if  membrane  is  present,  feathers  and  a  solution  of  bicar- 
^  See  Stephen  Paget's  Surgery  of  the  Air-passages. 


6o2 


MODERN  SURGERY. 


bonate  of  sodium.  In  a  formal  operation  give  chloroform, 
but  in  an  emergency  case  this  cannot  be  done.  The  patient 
may  be  placed  supine  with  a  sand-pillow  under  the  neck 
and  with  the  head  thrown  over  the  end  of  the  table.  If  a 
child,  Liston  used  to  wrap  it  up  to  the  neck  in  a  sheet  to 
prevent  movements  of  the  limbs,  would  seat  himself  on  a 
chair,  place  the  child  upon  the  nurse's  lap,  and  take  its  head 
between  his  knees.  If  bleeding  is  profuse  when  the  surgeon 
is  ready  to  open  the  trachea,  place  the  patient  in  the  Trendel- 
enburg position  with  the  neck  extended.  The  head  must 
be  exactly  in  the  middle  line,  and  extended  (in  an  adult  this 
gives  two  and  three-quarters  inches  of  trachea  above  the 
manubrium ;  in  a  child  of  ten,  two  and  a  quarter  inches ;  in 
a  child  of  six,  about  two  inches).  The  operator  stands  tO' 
the  right  side  when  the  patient  is  supine.  The  trachea  may 
be  opened  above  or  below  the  isthmus  of  the  thyroid  gland. 
The  isthmus  in  an  adult  usually  lies  over  the  second  and 
third  rings  (Fig.  184).     The  isthmus  in  a  child  usually  lies. 


Fig.  184. — Blood-supply  of  the  larynx  and 
trachea  (Esmarch  and  Kowalzig). 


Fig.  185. — Parts  exposed  in  tracheotomy 
(Esmarch  and  Kowalzig). 


over  the  first  ring  or  even  over  the  space  between  the  cri- 
coid cartilage  and  the  first  ring.  The  high  operation  is 
always  performed  except  in  cases  where  it  is  desired  to 
search  for  a  foreign  body  in  a  bronchus. 

High  Tracheotomy. — This  operation  is  preferred  be- 
cause in  this  region  the  muscles  are  distinctly  separated  (Fig. 
185),  the  main  vessels  of  the  neck  and  the  inferior  thyroid 
vessels  are  not  encountered,  the  anterior  jugular  veins  are 
small  and  have  very  few  transverse  branches,  and  the  trachea 


SUKGERV  OF  THE   RESPIRATORY  ORGANS.  603 

is  near  the  surface  (Treves).  Accurately  locate  the  cricoid 
and  th)Toid  cartilages.  An  incision  is  begun  at  the  upper 
border  of  the  cricoid  cartilage,  and  is  carried  down  precisely 
in  the  middle  line  for  about  one  and  a  half  inches.  Treves 
advises  the  operator  to  steady  the  skin  of  the  neck  with  the 
fingers  of  the  left  hand  and  to  cut  with  the  unsupported  right 
hand  (if  the  hand  be  supported,  the  respirations  will  interfere 
with  the  operation).  Incise  the  skin,  the  superficial  fascia,  and 
the  anterior  layer  of  the  cervical  fascia,  separate  the  sterno- 
hyoid and  sternothyroid  muscles,  and  divide  the  fascia  over 
the  trachea.  This  fascia  is  attached  above  to  the  cricoid 
cartilage,  and  it  divides  below  into  two  layers  to  invest  the 
thyroid  body  and  its  isthmus.  If  veins  are  in  the  line  of  the 
incision,  push  them  aside,  but  do  not  stop  to  apply  a  double 
ligature.  Even  if  bleeding  is  profuse,  as  soon  as  the  trachea 
is  opened  and  air  enters  freely  into  the  lungs  venous  conges- 
tion is  relieved  and  bleeding  is  apt  to  cease.  If  hemorrhage 
be  violent  and  the  veins  are  not  at  once  caught  by  forceps, 
it  may  be  well  to  place  the  patient  in  the  Trendelenburg 
position.  Before  opening  the  trachea  push  the  isthmus  of 
the  th}'roid  gland  down ;  if  it  cannot  be  pushed  down  suf- 
ficiently, make  a  transverse  incision  through  the  fascia  at  the 
upper  border  of  the  cricoid  cartilage,  and  lift  the  fascia,  and 
the  isthmus  with  it,  off  the  trachea  (Bose's  method).  In- 
sert a  tenaculum  into  the  cricoid  cartilage  in  order  to  steady 
the  tube.  Turn  the  back  of  the  knife  toward  the  sternum, 
hold  a  finger  on  the  blade  to  prevent  too  deep  a  cut  being 
made,  plunge  the  knife,  like  a  trocar,  into  the  mid-line 
of  the  trachea  above  the  isthmus,  and  divide  two  or  three 
rings  from  below  upward.  Do  not  remove  the  hook  until 
the  operation  is  completed.  If  a  foreign  body  is  present, 
try  to  remove  it ;  if  success  attends  the  effort,  no  tube 
need  be  worn,  but  if  the  body  is  not  found,  use  a  tube. 
In  croup  or  in  diphtheria  remove  membrane  (b}-  means 
of  a  feather  and  a  solution  of  bicarbonate  of  sodium  5ij, 
ghxerin  5J,  water  sx — Parker)  and  insert  a  tube.  Grasp  an 
edge  of  the  cut  with  the  dissecting-forceps,  include  the 
mucous  membrane  in  the  bite,  bring  the  head  erect,  intro- 
duce the  tube,  and  remove  the  tenaculum.  Secure  the  tube 
by  tapes,  and  suture  the  wound  below  the  tube.  Remove 
the  tube  at  the  first  moment  consistent  with  safet}'.  In 
croup  or  diphtheria  put  a  screen  around  the  bed ;  have 
the  air  moist  by  steam  ;  remove  the  inner  tube  and  clean 
every  two  or  three  hours  at  first ;  clean  the  outer  tube, 
and  the  larj-nx  and  trachea   whenever   required,  by  means 


604  MODERN  SURGERY. 

of  a  feather  and  Parker's  solution.  A  steam  spray  atomizer 
may  very  often  be  used  with  advantage. 

Quick  laryngotomy  must  never  be  attempted  upon  a 
child  under  thirteen  years  of  age,  because  of  the  small  size 
of  the  cricothyroid  space  before  this  age  (Treves.)  In 
view  of  the  difficulty  of  introducing  a  tube  and  of  wearing 
it  so  near  the  vocal  cords,  laryngotomy  should  not  be  per- 
formed for  croup,  diphtheria,  or  for  any  condition  in  which 
a  tube  must  be  long  worn.  An  incision  an  inch  and  a 
quarter  long  is  made  in  the  middle  line,  from  above  the 
lower  edge  of  the  thyroid  cartilage  to  below  the  lower 
border  of  the  cricoid.  Divide  the  skin,  superficial  fascia, 
and  deep  fascia,  separate  the  cricothyroid  and  sternothy- 
roid muscles,  divide  the  deep  layer  of  fascia,  and  cut  the 
cricothyroid  membrane  horizontally  just  above  the  cricoid 
cartilage.  The  tube  must  be  shorter  than  is  the  tracheotomy- 
tube.  An  operation  which  opens  vertically  the  cricothyroid 
membrane,  the  cricoid  cartilage,  and  the  upper  rings  of  the 
trachea  is  called  "  laryngotracheotomy." 

Intubation  of  the  I/arynx  (O'Dwyer's  Operation). — 
The  instruments  required  in  this  operation  are  a  mouth-gag, 
an  instrument  to  hold  the  tube  and  introduce  it,  an  instru- 
ment for  extracting  the  tube,  and  a  graduated  scale.  The 
collar  of  the  tube  has  a  perforation  through  which  a  piece  of 
silk  is  fastened  to  draw  out  the  tube.  The  child  is  wrapped 
in  a  sheet  to  secure  the  limbs,  is  seated  in  a  nurse's  lap,  and 
its  head  is  held  by  an  assistant.  The  jaws  are  to  be  opened 
and  held  apart  by  the  self-retaining  mouth-gag.  The  sur- 
geon sits  in  front  of  the  patient,  wraps  the  index  finger  of  his 
left  hand  with  a  piece  of  rubber  plaster,  and  passes  it  into  the 
child's  mouth  until  his  finger  touches  the  epiglottis.  He 
introduces  the  holder  and  tube  (observing  if  the  silk  is  free) 
along  the  surface  of  the  tongue  until  the  obturator  touches 
the  epiglottis ;  raises  the  epiglottis  with  the  left  index  finger, 
and  passes  the  tube  into  the  larynx ;  places  the  left  index 
finger  against  the  tube,  and  withdraws  the  holder  with  the 
right  hand.  The  silken  thread  is  tied  to  the  ear,  and  the 
nurse  is  directed  to  employ  the  thread  to  remove  the  obtu- 
rator if  it  becomes  obstructed  or  is  coughed  up.  The  tube 
is  removed  in  two  or  three  days  ;  if  breathing  is  easy,  it  is 
not  reintroduced,  but  if  dyspnea  recurs,  it  is  replaced  for 
two  or  three  days  more.  If,  in  introducing  the  tube,  a 
mass  of  false  membrane  is  pushed  before  it  into  the  trachea, 
breathing  ceases,  and,  if  the  mass  is  not  at  once  coughed 
up,  tracheotomy  must  be  performed.     Wharton  feeds  these 


SURGERY  OF   THE   RESPIRATORY  ORGANS.  605 

patients  on  semi-solids  rather  than  upon  hquids  (mush, 
soft  eggs,  and  corn-starch),  and  if  trouble  occurs  in  swal- 
lowing these  articles,  he  feeds  by  the  rectum  or  by  means 
of  a  tube. 

4.  Diseases   and    Injuries  of   the   Chest,   Pleura,    and 

Lungs. 

Pleuritic  effusion  may  arise  from  foreign  bodies,  from 
injury  by  fragments  of  a  broken  rib,  from  tumors,  and  from 
inflammation  of  the  lung,  but  most  usually  from  pleuritis. 
Inflammatory  effusion  is  nearly  always  unilateral  (except  in 
tubercular  pleurisy,  but  even  this  form  is  one-sided  at  the 
start). 

The  signs  of  pleuritic  effusion  are — dulness  on  percussion 
over  the  effusion,  this  dulness,  when  the  patient  is  erect, 
being  at  the  lower  part  of  the  chest  and  ascending  higher 
posteriorly  than  anteriorly  (alteration  of  position  alters  the 
situation  of  the  dulness) ;  the  intercostal  spaces  are  widened 
and  the  intercostal  depressions  are  obliterated ;  no  breath- 
sounds  can  be  detected  in  the  area  of  flatness  when  the  col- 
lection of  fluid  is  large,  but  in  small  effusions  deeply  situated 
the  breath-sounds  are  often  audible ;  the  percussion-note 
above  the  liquid  is  hyper-resonant  or  tympanitic,  and  is  often 
associated,  at  the  edge  of  the  liquid,  with  a  friction-sound ; 
posteriorly,  high  up  and  near  the  spine,  there  are  bronchial 
respiration  and  bronchophony  (DaCosta).  In  these  cases 
pain  disappears  with  the  advent  of  effusion,  dyspnea  comes 
on,  and  the  patient  lies  upon  the  diseased  side.  Cough  and 
fever  always  exist.  In  serous  effusions  the  diagnosis  may  be 
confirmed  by  the  introduction  of  an  asepticized  aspirating- 
needle. 

The  treatment  in  this  stage  is  to  discontinue  arterial  seda- 
tives and  to  stimulate  if  the  circulation  calls  for  it.  The 
exudation  is  removed  by  salines,  by  compound  jalap  powder, 
or  by  elaterium.  If  these  means  fail,  if  the  effusion  is  exces- 
sive, or  if  it  is  producing  dyspnea,  at  once  aspirate.  If  pus 
forms,  drain  by  operation. 

Kmpyetna  is  a  collection  of  pus  in  the  pleural  cavity.  It 
may  begin  suddenly,  but  rarely  does  so.  Among  the  causes 
of  empyema  are  those  of  serous  effusion.  Empyema  is  due 
to  infection  of  the  pleura.  The  pneumococcus  is  the  causa- 
tive organism  in  many  of  the  cases  which  follow  pneumonia. 
This  organism  lives  but  a  short  time,  and  an  empyema  due  to 
pneumococci   may   possibly  be   absorbed   (Stephen  Paget). 


6o6"  MODERN  SURGERY. 

Most  cases  of  empyema  are  due  to  streptococci  and  staphylo- 
cocci. These  organisms  may  appear  in  an  empyema  induced 
originally  by  pneumococci  (Stephen  Paget).  In  empyema  de- 
veloping during  or  after  typhoid  fever  the  typhoid  bacillus 
may  be  discovered.  In  putrid  empyema  various  bacteria 
are  found.  Bouchard  thinks  acute  empyema  has  a  special 
organism.  The  bacilli  of  tuberculosis  are  present  in  tuber- 
cular empyema.  Empyema  may  be  due  to  a  wound'  or 
contusion,  an  attack  of  pneumonia,  tubercular  pleurisy, 
phthisis,  typhoid  fever,  infection  of  a  serous  effusion,  caries 
of  a  rib,  specific  fevers,  peritonitis,  malignant  disease  of  the 
pleura,  or  gangrene  of  the  lung.  The  signs  are  in  reality 
those  of  pleurisy  with  effusion,  viz.,  dulness  on  percussion, 
absent  breath-sounds,  bulging  of  the  intercostal  spaces,  and 
sometimes  edema  of  the  skin  of  the  chest.  The  symptoms 
are  irregular  fever,  sweats,  chills,  dyspnea,  pallor,  and  some- 
times cough.  There  is  marked  leukocytosis.  The  fingers 
may  become  clubbed.  An  empyema  of  the  left  side  may 
pulsate.  A  neglected  empyema  may  break  into  the  lungs, 
esophagus,  or  pericardium,  or  may  point  in  the  lumbar  region. 
Empyema  may  cause  death  by  compression  of  the  heart  and 
lung,  pulmonary  embolism,  pericarditis,  peritonitis,  cerebral 
embolism,  cerebral  abscess,  septicemia  (Stephen  Paget),  or 
exhaustion. 

The  treatment  is  aspiration,  incision  and  drainage,  or 
thoracoplasty  (see  pages  608-610). 

Contusions  and  Wounds  of  the  Chest. — The  symp- 
toms of  contusions  of  the  chest  are  pain  and  soreness,  and,  as 
a  consequence,  abdominal  respiration  and  decubitus  upon 
the  back  inclining  to  the  injured  side.  In  severe  contusions 
the  viscera  may  be  injured.  The  treatment  is  by  strapping 
the  chest  as  for  fractured  ribs  (PI.  5,  Fig.  13).  Non-penetrat- 
ing wounds  of  the  chest  are  not  especially  grave,  and  are 
treated  according  to  general  rules,  the  chest  being  immob- 
ilized. Penetrating  wounds  are  very  grave  injuries.  Visceral 
injury  may  be  inflicted.  Emphysema  is  apt  to  occur.  Pro- 
fuse hemoptysis  suggests  a  wound  of  the  lung.  In  ex- 
amining chest-wounds  feel  with  a  finger,  not  with  a  probe. 
In  wounds  of  the  pleura  cleanse,  stitch  the  pleura  with  cat- 
gut or  fine  silk,  suture  the  skin,  dress  with  gauze,  and  immob- 
ilize the  chest.  Wounds  of  the  lung  demand  absolute  rest. 
If  the  bleeding  is  slight,  do  not  operate ;  but  if  bleeding 
threatens  life,  resect  a  rib  to  reach  the  lung,  and  arrest  hem- 
orrhage. Hemorrhage  of  the  lung  may  in  some  cases  be 
arrested  by  the  ligature,  in  some  cases  by  packing  a  small 


SURGERY  OF   THE   RESPIRATORY  ORGANS.  607 

wound  with  gauze,  in  some  cases  by  the  suture  ligature.  In 
a  violent  secondary  hemorrhage  following  a  gunshot-wound 
of  the  lung  the  author  packed  the  entire  pleural  cavity  with 
sterile  gauze  to  obtain  a  base  of  support,  and  arrested  the 
bleeding  by  carrying  iodoform  gauze  directly  against  the 
oozing  surface/  After  arresting  hemorrhage  in  hemothorax, 
turn  out  the  clots  and  employ  drainage.  If  emphysema  of 
the  chest-walls  is  moderate,  strapping  or  a  bandage  will  con- 
trol it ;  if  it  is  great,  make  multiple  punctures  and  then  apply 
pressure.  In  hernia  of  the  lung  try  to  restore  the  protru- 
sion, but  if  restoration  is  impossible  or  if  gangrene  seems 
highly  probable,  ligate  the  base  of  the  protrusion  with  silk 
and  cut  away  the  mass.  If  foreign  bodies  in  the  thorax 
can  be  felt,  remove  them  ;  if  they  cannot  be  felt,  do  not 
conduct  a  prolonged  search,  but  leave  them  to  Nature. 

Abscess  of  the  lung  may  follow  ordinary  pneumonia. 
It  is  apt  to  follow  aspiration  pneumonia.  Osier  tells  us  that  it 
may  arise  by  the  aspiration  of  septic  particles  after  "  wounds 
of  the  neck,  operations  upon  the  throat,"  and  suppurative 
lesions  of  the  nose,  larynx,  or  ear.  Cancer  of  the  esophagus 
may  be  a  cause,  so  may  perforation  of  the  lung  by  an  abscess, 
wound  of  the  lung,  impaction  of  a  foreign  body  in  the  lung, 
suppuration  about  a  focus  of  tubercle  or  metastatic  abscess.^ 

Symptoms. — The  physical  signs  of  a  large  cavity  are 
found,  and  there  is  profuse  and  offensive  expectoration, 
the  expectorated  matter  containing  portions  of  lung-tissue. 
Pyemic  abscesses  are  hard  to  diagnosticate. 

The  treatment  is  purely  surgical  (Pneumotomy).  Make 
an  incision  over  the  cavity.  Resect  a  portion  of  one  or  more 
ribs.  Expose  the  pleura.  If  the  two  layers  of  the  pleura 
are  not  adherent,  suture  them  together  and  wait  two  days. 
If  they  are  adherent,  proceed  at  once.  Search  for  the  ab- 
scess with  an  aspirator.  When  the  cavity  is  found,  open  into 
it  with  the  cautery  and  insert  a  drainage-tube. 

Gangrene  of  the  I/Ung. — This  term  means  the  putre- 
faction of  a  devitalized  portion  of  pulmonary  tissue.  It  may 
follow  pneumonia,  or  may  be  due  to  diabetes,  to  embolism  of 
the  pulmonary  artery,  bronchiectasis,  tuberculosis,  or  malig- 
nant disease. 

Symptoms. — The  symptoms  of  a  cavity  exist  plus  the 
expectoration  of  horribly  offensive  sputum,  which  contains 
fragments  of  lung-tissue  and  often  altered  blood  ;  there  is 
some  fever,  and  great  exhaustion.     The  great  fetor  of  the 

1  Annals  of  Surgery,  Jan.,  1898. 
'^  See  Osier's  Practice  of  Medicine. 


6o8  MODERN  SURGERY. 

discharge  is  characteristic,  and  is  much  more  intense  than  the 
fetor  of  abscess. 

The  treatment  is  to  operate  as  for  pulmonary  abscess. 

Tubercular  Cavity  in  tlie  I/Ung. — Surgical  Treat- 
ment.—  For  the  past  decade  surgical  thought  has  been 
actively  directed  toward  placing  on  a  scientific  footing  op- 
erations for  pulmonary  phthisis.  The  matter  is  still  in  a 
transition  stage,  and  operations  at  present  have  but  a  very 
limited  field  of  application,  although  Sonnenberg  and  others 
have  reported  cures.  Hosier,  a  number  of  years  ago,  at- 
tempted to  treat  cavities  by  introducing  a  trocar  into  the 
cavity  and  injecting  permanganate  of  potassium  solution 
through  the  cannula.  Patients  were  not  benefited  by  this 
procedure.  Hillier  tried  injection  of  corrosive  sublimate 
into  the  lung-parenchyma,  but  the  effect  of  the  injections  was 
disastrous.  When  the  strength  of  the  patient  is  well  preserved 
and  the  pulmonary  lesion  is  circumscribed  and  slowly  pro- 
gressive it  may  be  justifiable  to  perform  an  operation,  open 
the  cavity,  and  treat  it  directly  (pneumotomy).  Fowler  says 
it  is  not  justifiable  to  operate  if  the  disease  has  come  "  to  a 
standstill."  The  same  surgeon  states  that  the  only  accessible 
region  is  bounded  above  by  the  clavicle,  to  the  inner  side  by 
the  manubrium,  to  the  outer  side  by  the  lesser  pectoral  mus- 
cle, and  below  by  the  second  rib.^ 

Manclaise  says  that  pneumotomy  is  only  justifiable  in  cir- 
cumscribed tubercular  cavities  without  peripheral  infiltra- 
tion and  in  pulmonary  abscesses.^  Bronchiectatic  cavities  are 
usually  multiple;  they  are  excessively  difficult  to  locate,  and 
treatment  by  pneumotomy  should  not  be  attempted.  In  the 
treatment  of  pulmonary  tuberculosis  resection  of  the  diseased 
area  has  been  proposed  (pneumectomy).  Tufifier  successfully 
performed  this  operation.  Surgeons,  as  a,  rule,  do  not  believe 
in  pneumectomy.  Reclus  voices  the  general  opinion  when 
he  says  the  operation  is  not  required  if  the  area  of  disease  is 
very  limited,  as  such  a  condition  is  frequently  curable  by 
medical  means,  and  it  does  no  good  if  the  area  of  disease  is 
extensive.^ 

Paracentesis  Thoracis. — Aspiration  will  very  rarely  cure 
empyema.  It  will  occasionally  cure  a  small  encysted  empyema 
or  a  pneumococcus  empyema  in  a  child.  Its  chief  use  is  in 
diagnosis,  or  as  a  temporary  measure  when  dyspnea  is  severe 

^  See   the  very  full  and  thoughtful  article  of   George  Ryerson  Fowler  on 
"The  Surgery  of  Intrathoracic  Tuberculosis,"  ^««a/5  of  Surg.,  Nov.,  1896. 
'  La  Tribune  inedicale,  Sept.  21,  1893. 
^  Revue  de  Chiru7-gie,  Nov.  Ii,  1895. 


SURGERY  OF   THE  RESPIRATORY  ORGANS. 


609 


or  when  operation  is  not  indicated.  In  very  large  effusions 
it  is  wise  to  aspirate  and  withdraw  part  of  the  effusion  several 
days  before  doing  a  radical  operation.  After  the  aspiration 
the  patient  takes  an  anesthetic  with  more  safety,  and  the 
danger  is  obviated  of  suddenly  evacuating  a  large  effusion. 
The  trocar  must  not  be  used  except  in  an  emergency ;  the 
aspirator  is  greatly  to  be  preferred.  The  aspirator  evacu- 
ates the  fluid,  and,  as  bacteria  do  not  enter,  the  lung  ex- 
pands and  infection  does  not  occur.  The  skin,  the  instru- 
ments, and  the  surgeon's  hands  must  be  asepticized.  Give 
the  patient  a  little  whiskey,  and,  unless  he  is  very  weak,  make 
him  sit  up  in  bed.  The  arm  hangs  by  the  side,  and  the  sur- 
geon introduces  the  needle  in  the  fifth  interspace,  just  in  front 
of  the  angle  of  the  scapula.  The  surgeon  marks  the  upper 
border  of  the  sixth  rib  with  the  index  finger,  and  plunges  in 
the  needle  just  above  the  finger,  thus  avoiding  the  intercostal 
artery,  which  lies  along  the  lower  border  of  the  rib  above. 
Always  guard  the  needle  with  a  finger  to  prevent  its  going 
in  too  far.  After  withdrawing  the  needle,  place  iodoform 
collodion  over  the  opening  into  the  chest.  In  pleuritic  effu- 
sion, if  the  lungs  will  not  expand  after  tappings,  perform 
thoracotomy. 

Thoracotomy  is  an  incision  into  the  cavity  of  an  em- 
pyema. It  may  be  merely  an  intercostal  incision,  or  may  be 
an  opening  into  the  chest  after  resecting  a  portion  of  a 
rib.  The  instruments  required  are  a  scalpel,  a  grooved 
director,  forceps  (hemostatic  and  dissecting-),  scissors,  a  dry 
dissector,  retractors,  bone-instruments  (in  case  rib-excision 
is  required),  drainage-tubes,  and  needles.  Chloroform  is 
given  the  patient,  who  lies  supine  at  the 
edge  of  the  table,  with  the  arm  elex^ated 
to  a  right  angle  with  the  body.  Make 
an  incision  about  three  inches  in  length 
along  the  upper  border  of  the  lower  rib 
bounding  the  space  it  is  proposed  to 
penetrate.  This  space  is  either  the  sixth 
or  the  seventh,  and  the  desired  site  is  in 
front  of  the  posterior  axillary  fold.  Incise 
the  superficial  structures,  divide  the  inter- 
costal muscles  near  the  rib,  push  a  grooved 
director  through  the  pleura,  and  enlarge 
the  opening  by  means  of  forceps  and  the 
finger.  The  finger  removes  all  masses  of  tubercular  mate- 
rial or  aplastic  lymph  within  reach.  Some  surgeons  advo- 
cate immediate  irrigation,  but  this  procedure  is  unsafe,  as  it 

39 


Fig.  i85. — Resection  of 
rib  (Esmarch  and  Kowal- 
zig). 


6 10  MODERN  SURGERY. 

may  produce  dyspnea  or  pleuritic  epilepsy,  and  has  caused 
death.  In  some  cases  a  counter-opening  is  made  by  cutting 
down  upon  the  long  probe  which  is  pushed  against  the  chest- 
wall  after  being  introduced  through  the  incision ;  in  other 
cases  it  is  necessary  to  resect  a  rib  (page  609 ;  Fig.  1 86). 
A  short  drainage-tube  is  introduced  and  stitched  in  place.  If 
a  counter-opening  has  been  made  introduce  another  short 
tube,  but  do  not  pull  one  tube  through  both  openings.  Arrest 
bleeding,  suture  the  skin,  dust  with  iodoform,  dress  with 
gauze,  wood-wool,  and  a  binder,  and  have  the  dressings 
changed  as  .soon  as  they  become  soaked  at  one  point.  This 
operation  is  rarely  curative,  and  in  most  cases  the  intercostal 
spaces  are  too  narrow  to  permit  of  satisfactory  drainage.  It 
is  far  better  to  remove  a  piece  of  rib  as  directed  on  page  609 
(see  Fig.  186).  Remove  the  periosteum  and  open  the  pleura. 
After  opening  the  pleura  insert  a  finger  into  the  pleural  cavity. 
Note  if  the  lung  can  expand.  If  it  is  evident  that  it  can  ex- 
pand, insert  a  short  drainage-tube,  close  the  soft  parts,  and 
dress.  Several  times  a  day  change  the  patient's  position. 
At  each  change  have  him  on  the  diseased  side  for  half  an 
hour,  and  with  the  foot  of  the  bed  raised  for  half  an  hour. 
Favor  expansion  by  causing  the  patient  to  blow  into  a  wash- 
bottle  filled  with  water.  Remove  the  tube  when  the  dis- 
charge becomes  thin  and  scanty  (about  the  eighth  or  tenth 
day,  as  a  rule).  If  the  lung  is  bound  down  with  adhesions 
and  cannot  expand  to  fill  the  space  vacated  by  the  pus,  per- 
form the  operation  of  Schede  or  Estlander. 

Thoracoplasty  (Estlander's  operation)  is  employed  in 
old  cases  of  empyema  in  which  drainage  has  failed,  and  in 
cases  with  retracted  chest-walls,  collapsed  lungs,  thickened 
pleura,  and  cavities  whose  rigid  walls  will  not  collapse. 
The  procedure  recognises  the  fact  that  after  pus  is  evacuated, 
if  the  lung  is  adherent,  it  cannot  expand  to  fill  the  space  once 
occupied  by  fluid,  and  that  the  rigid  chest  cannot  fall  in  as  a 
substitute  for  the  lung,  and  seeks  to  destroy  the  rigidity  of 
the  chest  and  permit  it  to  collapse  and  thus  obliterate  the 
cavity  of  the  empyema.  When  the  surgeon  resects  a  rib  and 
finds  a  cavity  with  uncollapsable  walls,  or  a  lung  bound  down 
with  firm  adhesions,  he  should  perform  thoracoplasty.  This 
operation  causes  the  obliteration  of  the  cavity  by  collapsing 
that  portion  of  the  chest-wall  overlying  it.  The  cavity  is  in 
the  upper  or  central  part  of  the  pleural  space  (Treves).  The 
instruments  required  are  the  same  as  those  for  resection 
of  a  rib.  The  position  is  the  same  as  that  for  rib-resec- 
tion.    The  length  of  the  incision  depends   on  the  size  of 


SURGERY  OF   THE   RESPIRATORY  ORGANS. 


6ii 


the  cavity.  The  surgeon  usually  removes  portions  of  the 
second,  third,  fourth,  fifth,  sixth,  and  seventh  ribs.  Make  a 
transverse  incision  along  the  center  of  an  intercostal  space, 
and  through  this  incision  remove  the  ribs  above  and  below 
by  the  method  set  forth  on  page  609  (the  removal  of  six 
ribs  will  require  three  incisions).  Instead  of  this  incision,  we 
can  make  a  vertical  incision  or  a  U  shaped  flap.  Always 
take  away  the  periosteum.  Treves  recommends  that  the 
cavity  be  at  once  washed  out  with  corrosive  sublimate 
(i  :  1000);  that  if  small  it  be  packed  with  iodoform  gauze 
and  allowed  to  granulate  ;  that  if  large  it  be  drained  by  a 
large  tube,  the  skin  being  sutured  by  silkworm-gut.  Irri- 
gation is  thought  by  many  to  be  dangerous  and  to  possess 
no  special  power  for  good. 

Schede's  Operation. — Schede  showed  that  when  the 
pleura  is  much  thickened 
even  Estlander's  operation 
will  not  permit  the  chest-wall 
to  collapse  and  fill  the  cavity 
once  occupied  by  the  fluid. 
Instruments,  same  as  for  Est- 
lander's operation,  plus  bone- 
shears.  A  U-shaped  flap  is 
made  from  the  level  of  the 
axilla  in  front  to  the  level  of 
the  second  rib  and  between 
the  scapula  and  spine  behind. 
The  lowest  level  of  this  incis- 
ion corresponds  to  the  lowest 
limit  of  the  pleura  (Fig.  187). 
The  flap  is  loosened  and 
raised,  and  the  scapula  is 
lifted  with  it.  The  ribs  from 
the  second  rib  down  and 
from  the  costal  cartilages  to 
the  tubercles  are  removed,  along  with  the  chest-muscles 
and  the  pleura.  This  is  accomplished  by  cutting  with 
bone-shears  and  scissors.  Hemorrhage  is  arrested.  The 
pleura  is  curetted.  A  drainage-tube  or  a  piece  of  iodo- 
form gauze  is  introduced,  and  the  raw  flap  is  laid  against 
the  visceral  layer  of  the  pleura.  The  superficial  incision 
is  sutured. 

Pneumotomy  for  Abscess  of  the  I/Ung. — The  instru- 
ments required  are  scalpels,  hemostatic  forceps,  dissecting- 
forceps,  dry  dissector,  retractors,  periosteum  elevator,  meta- 


FiG.  187. — Incision  for  Schede's  operation  of 
thoracoplasty  (Esmarch  and  Kowalzig.) 


6l2  MODERN  SURGERY. 

carpal  saw,  scissors,  needles,  curved  and  straight,  Paquelin's 
cautery. 

Operation, — Place  the  patient  recumbent  with  the  shoul- 
ders a  little  raised.  Make  a  U-shaped  flap  over  the  suspected 
trouble.  If  the  intercostal  spaces  are  wide,  cut  down  in  a  space 
to  the  pleura.  If  they  are  not  wide,  resect  a  rib.  If  it  is 
found  that  adhesions  do  not  exist  between  the  pulmonary  and 
costal  layers  of  the  pleura,  stitch  these  layers  together  with 
catgut  and  postpone  further  operation  for  forty-eight  hours. 
If  adhesions  exist,  proceed  at  once.  Incise  the  aggluti- 
nated layers  of  the  pleura,  and  pass  an  aspirating-needle 
into  the  lung  in  various  directions.  When  the  abscess  is 
located  open  it  by  the  cautery.  Carry  the  Paquelin  cautery 
slowly  into  the  lung  in  the  direction  of  the  abscess-cavity. 
The  cautery-knife  should  be  at  a  dull-red  heat. 

Fowler  calls  attention  to  the  fact  that  lung-tissue  is  so 
insensitive  that  the  administration  of  ether  can  be  suspended 
as  soon  as  the  pleura  has  been  opened.  When  the  cautery 
opens  the  cavity  withdraw  the  instrument  and  insert  a  drain- 
age-tube or  a  bit  of  iodoform  gauze,  and  suture  the  flap  of 
superficial  tissue.  If  the  abscess  is  not  found  after  one  or 
two  punctures  with  the  aspirating-needle,  abandon  the 
attempt. 

Tuffier  explores  for  an  abscess  by  what  he  calls  decolle- 
ment  of  the  parietal  pleura.  He  exposes  the  parietal  layer, 
passes  his  hand  between  this  layer  and  the  chest-wall,  strips 
the  pleura  off  over  a  considerable  area,  and  is  able  to  feel 
the  lung  below,  and  thus  determine  its  condition. 

XXVI.    DISEASES    AND     INJURIES    OF    THE    UPPER 
DIGESTIVE    TRACT. 

Diseases  of  the  Mouth,  Tongue,  and  Bsophagus. 

— Harelip  and  Cleft  Palate. — Harelip  is  a  congenital  cleft 
in  the  upper  lip  due  to  defective  development.  Cleft  palate 
is  a  congenital  fissure  in  the  soft  palate  or  in  both  the  hard 
and  soft  palates.  In  harelip  the  cleft  is  usually  complete, 
through  the  entire  lip  into  the  nostril,  but  in  rare  cases  it 
may  only  show  as  a  furrow  in  the  mucous  edge  or  as  a  split 
from  the  nostril  partly  into  the  lip.  It  is  most  common  on 
the  left  side.  In  double  harelip  the  central  portion  of  the 
lip  is  often  adherent  to  the  tip  of  the  nose  (Bowlby).  Double 
harelip  may  be  free  from  complication,  but  is  often  associated 
with  a  malformation  of  the  alveolus  and  palate  (Heath). 
Median    harelip   is    exceedingly   rare.     In    cleft   palate   the 


DISEASES  AND  INJURIES  OF  THE  DIGESTIVE  TRACT.   613 

septum  of  the  nose  is  usually  adherent  to  the  palatine  proc- 
ess opposite  the  side  upon  which  the  fissure  exists.  In 
those  rare  cases  of  cleft  palate  double  in  front  the  nasal  sep- 
tum is  attached  only  to  the  premaxillary  bone,  and  the  pre- 
maxillary  bone  is  not  attached  at  all  to  the  superior  maxillae. 
In  harelip  there  is  often  a  cleft  in  the  alveolus,  and  almost 
always  flattening  of  the  corresponding  side  of  the  nose. 
Harelip  is  often  associated  with  cleft  palate,  talipes,  and 
other  deformities.  It  is  a  great  deformity,  and  interferes 
with  sucking,  swallowing,  and  articulation. 

Operation  for  harelip  should  be  performed  between  the 
third  and  sixth  months  of  life  in  a  child  in  good  health,  free 
from  stomach  trouble,  cough,  or  coryza,  but  operation  is  not 
advisable  in  the  early  weeks  of  life.  Always,  if  possible, 
operate  before  dentition  begins  (seventh  month).  If  the 
child  is  in  poor  health,  postpone  the  operation  until  restora- 
tion has  so  far  advanced  as  to  render  operation  safe.  While 
waiting  for  operation  be  sure  the  child  is  getting  enough 
food.  If  it  cannot  suck,  feed  it  with  a  spoon.  If  a  cleft 
exists  in  the  palate,  operate  first  upon  the  lip,  because  the 
pressure  of  the  parts  after  the  edges  of  the  gap  are  approxi- 
mated aids  in  the  closure  of  the  bony  cleft.  Cleft  palate 
interferes  with  sucking,  deglutition,  mastication,  and  articu- 
lation. In  severe  cases  the  food  passes  into  the  nose  and 
excites  inflammation.  Loss  of  control  of  the  palate-muscles 
always  exists,  and  liquids  and  solids  are  liable  to  pass  into 
the  windpipe.  Clefts  in  the  hard  palate  should  not  be  oper- 
ated on  until  the  second  year,  but  should  be  operated  upon 
then,  otherwise  speech  will  be  permanently  affected.  Some 
surgeons  refuse  to  operate  until  the  tenth  or  twelfth  year, 
but  operation  done  this  late  will  not  correct  speech-defect. 
In  many  cases  the  passage  of  food  and  drink  into  the  nose 
can  largely  be  prevented  by  the  use  of 
a  diaphragm.  The  patient  at  the  period 
of  operation  should  be  well  and  free  from 
cough. 

Operation  for  Harelip. — The  instru- 
ments required  are  a  tenotome,  harelip- 
clamps,  toothed  forceps,  hemostatic  for- 
ceps,  scissors   curved   on   the   flat   and 

•     ,1       i'ii.Li        J.  •    L     ^         •  Fig.  188. — Malgaigne's  opera- 

pomted,  straight  blunt-pomted  scissors,  uon  for  harelip, 

needles  (straight  and  curved),  silver  wire 
or  silkworm-gut  and  silk  sutures,  a  mouth-gag  and  tongue- 
forceps,    a    needle-holder,     and     sequestrum-forceps,    each 
blade  protected  by  a  rubber  tube.     Wrap   the  child  in   a 


6 14  MODERN  SURGERY. 

sheet;  place  it  supine;  raise  the  head  and  rest  it  upon  a 
sand-pillow.  The  surgeon  stands  to  the  right  side  of  the 
patient.  Ether  or  chloroform  is  given.  For  single  harelip, 
separate  with  the  scissors  the  upper  lip  from  the  bone  on 
each  side  of  the  cleft  until  approximation  of  the  cleft  can 
be  effected  without  tension.  If  the  maxillary  bone  of  one 
side  projects  more  than  its  fellow,  grasp  it  with  sequestrum- 
forceps  and  bend  it  back  (Jacobson  and  Treves).  Clamp 
the  upper  lip  at  each  angle  of  the  mouth  to  prevent  hemor- 
rhage. If  the  edges  are  of  equal  or  nearly  equal  length, 
and  if  the  gap  is  not  very  wide,  perform  Malgaigne's  opera- 
tion. This  is  performed  as  follows :  a  flap  is  detached  on 
each  side,  the  detachment  beginning  at  the  upper  angle  of  the 
gap  ;  each  flap  is  detached  above  but  remains  attached  below. 
The  flaps  are  drawn  downward  so  as  to  form  a  prominence 
at  the  vermilion  border  (Fig.  i88).  If  the  edges  are  pared 
so  that  in  closure  the  vermilion  border  is  even,  when  the  parts 
are  healed  a  gutter  will  be  visible  at  the  line  of  union.  The 
edges  are  approximated  by  an  assistant,  and  silkworm-gut 
sutures  or  silver  wires  are  passed  by  means  of  a  straight 
needle.  Each  suture  goes  down  to  the  mucous  membrane. 
The  first  suture  is  passed  through  the  middle  of  the  lip,  one- 
third  of  an  inch  from  the  cleft.  Three  or  four  main  sutures 
are  passed  through  the  thickness  of  the  lip,  and  are  tied  and 
cut  off  Two  or  three  fine  silk  or  catgut  sutures  are  passed 
by  a  curved  needle  through  the  vermihon  border  of  the  lip 
and  the  mucous  membrane  of  the  mouth,  and  are  tied  and  cut 
off.  A  small  piece  of  gauze  is  placed  over  the  lip  and  is  held 
in  place  by  straps  of  rubber  plaster.  After  operation  prevent 
the  child  crying  by  feeding  it  often  and  giving  it  small  doses 
of  laudanum.  Heath  orders  two  drops  of  laudanum  in  one 
ounce  of  distilled  water,  a  teaspoonful  to  be  given  every  two 
or  three  hours.  About  the  sixth  day  one-half  the  sutures 
are  taken  out,  and  on  the  eighth  or  ninth  day  the  remaining 
ones  are  removed.  In  many  cases  no  further  procedure  is 
necessary,  but  if  after  some  weeks  the  prominence  at  the  lip- 
border  does  not  shrink,  it  can  be  readily  clipped  away. 
Harelip-pins  are  not  used  at  the  present  time,  and  are  not 
needed  if  the  lip  is  well  separated  from  the  bone.  If  the 
edges  of  the  cleft  are  of  unequal  length,  Edmund  Owen's 
operation  can  be  performed  (see  below  under  Double  Harelip), 
or  we  can  perform  Mirault's  operation,  as  shown  in  Fig.  190. 
In  double  harelip  the  operation  is  similar  to  that  for  single 
harelip.  If  the  intervening  piece  is  vertical  and  is  covered  with 
healthy  skin,  complete  each  operation  as  for  single  harelip, 


DISEASES  AA'D  INJURIES  OF  THE  DIGESTIVE  TRACT.    615 


closing  both  fissures  at  once  with  silver  wire  in  a  strong, 
healthy  child,  closing  them  at  intervals  of  three  weeks  in  one 
not  so  lusty  (Fig.  189).     Excise  the  septum  if  it  is  deformed. 

The    premaxillary   bone   should 
in    most  instances  be  removed, 


Fig.  180. — Incisions  for  double  harelip 
(Esmarch  and  Kowalzig). 


Fig.  190. — JNIirault's  operation  for  single 
harelip  (Esmarch). 


the  skin  over  it  being  preserved.  Sir  Wm.  Fergusson  was 
accustomed  to  incise  the  mucous  membrane  and  shell  out 
this  bone.  The  premaxillary  bone  can  be  forced  back  into 
line,  being  held,  if  necessary,  by  catgut  suture  of  the  peri- 
osteum ;  but  if  saved  it  is  liable  to  necrose  and  its  teeth  soon 
decay.  Heath  removes  this  bone  two  weeks  before  operating 
on  the  lip.  If  there  is  much  hemorrhage  after  removal,  stop 
it  with  a  hot  wire  or  with  Horsley's  wax.  Fig.  189  shows 
incisions  for  double  harelip.  Edmund  Owen's  operation  is 
very  useful  (Figs.  191,  192).  In  this  operation  very  thick 
flaps  are  cut.  The  prolabium  and 
incisive  bone  are  removed.  The 
flaps  are  cut  as  shown,  Fig.   191, 


Fig.  191. — Double  harelip,  the  prolabium  and 
incisive  bone  having  been  removed  (Owen). 


Fig.  192. — The.two  sides  of  the  lip  drawn 
together  and  secured  by  sutures  (Owen). 


on  one  side  by  line  ab,  and  on  the  other  side  by  line  cde.  a 
is  brought  to  e,  b  is  brought  to  d,  f  is  brought  to  c,  and 
sutures  are  applied  (Fig.   192). 

Operation  for  Cleft  Palate. — It  is  true  that  during  the  early 
years  of  growth  the  clefts  diminish  in  size ;  but  to  wait  too 
long  before  we  operate  means  permanent  speech-impairment. 
Bony  clefts  should  be  operated  upon  during  the  second  year 
(Owen).  Clefts  of  the  soft  palate  only  may  be  operated 
upon  in  the  first  six  months  (Edmund  Owen).  If  both  the 
hard  and  soft  palates  are  cleft,  close  both  at  one  operation. 
Edmund  Owen  has  recently  put  forth  a  convincing  plea  for 


6 1 6  MODERN  SUR GER  Y. 

early  operation.^  He  says  he  is  operating  earlier  and  earlier, 
and  quotes  Chilton  as  the  gentleman  who  led  him  to  do  so. 
Owen  maintains  that  if  speech  is  to  be  improved  operation 
must  be  done  early,  and  he  formulates  some  very  valuable 
rules  of  preparation  and  cafe :  have  the  child  in  the  best 
condition,  free  from  cough  and  stomach  disorder.  Operate 
in  the  summer.  Place  the  child  under  the  charge  of  a  nurse 
several  days  before  the  operation.  For  suture  of  the  soft 
palate  istapliylorrhaph)')  Treves  says  the  following  instru- 
ments are  essential :  two  sharp-pointed  tenotomes,  a  blunt- 
pointed  tenotome,  a  rectanglar  knife,  two  pairs  of  long  forceps 
(one  with  tenaculum  points,  one  serrated),  a  fine  hook,  a  pair 
of  sharp-pointed  curved  scissors,  scissors  curved  on  the  flat, 
periosteum-elevators,  two  long-handled  needles  with  eyes  at 
their  points,  a  suture-catcher,  a  tubular  needle  for  wire  su- 
tures, hemostatic  forceps.  Whitehead's  gag  and  retractors, 
silver  wire,  silkworm-gut,  and  sponge-holders ;  also  an  elec- 
tric forehead  light.  The  patient's  body  is  raised,  and  his  head 
is  elevated  and  rested  upon  a  sand-bag.  A  better  position 
would  be  that  of  Trendelenburg,  thus  avoiding  the  trickling 
of  blood  into  the  windpipe.  Chloroform  is  given.  The  gag 
is  introduced;  the  edges  of  the  mucous  membrane  are  pared 
with  a  tenotome ;  the  sutures  are  introduced  from  below  up- 
ward, silkworm-gut  being  used  for  the  uvula  and  lower  part 
of  the  velum,  silver  wire  for  the  remainder  of  the  cleft ;  each 
suture,  as  it  is  passed,  is  tied  or  twisted,  but  is  not  cut  until 
the  next  suture  is  inserted,  thus  serving  as  a  handle.  If 
there  is  too  much  tension  to  allow  of  the  sutures  being  tied 
as  they  are  inserted,  all  the  sutures  are  passed  and  loosely 
twdsted.  A  longitudinal  incision  is  made  upon  each  side,  in- 
ternal to  the  hamular  process,  the  mucous  membrane  being 
cut  with  a  sharp  tenotome,  the  deeper  structures  being  di- 
vided with  a  blunt  tenotome ;  the  sutures  are  tied  or  twisted 
and  cut  (Fig.  193).  In  Fergusson' s  operation  for  clefts  in  the 
hard  palate  {iiranoplastyi)  the  mucous  edges  are  pared  and 
the  sutures  inserted  but  not  tied.  Make  an  incision  upon 
each  side  down  to  the  bone,  the  incision  being  midway  be- 
tween the  cleft  and  the  alveolus.  Divide  the  bone  on  each 
side,  by  means  of  a  chisel,  to  the  full  length  of  the  incision, 
and,  using  the  chisel  as  a  lever,  force  each  half  of  the  bone 
toward  the  gap.  Tie  the  sutures,  and  plug  each  lateral  in- 
cision with  a  piece  of  iodoform  gauze  (Fig.  194).  After  the 
operation  for  cleft  palate  put  the  patient  to  bed  for  one  week ; 
forbid  talking ;  give  fluid  or  semisolid  food  at  intervals  of  two 

1  Lancet,  Jan.  4,  1896. 


DISEASES  AND  INJURIES  OF  THE  DIGESTIVE  TRACT.    617 


or  three  hours  for  three  weeks ;  wash  out  the  mouth  very 
often  (always  after  eating)  with  a  carbohc  solution  (i  :  100) 
or  a  solution  of  boric  acid  and  listerine.  Sutures  are  re- 
moved in  from  two  to  three  weeks. 

Edmund  Owen '    operates   as   follows :    pare   a   strip  of 


Fig.  193. 


-Staphylorrhaphy  (Esmarch 
and  Kowalzigj. 


Fig.  194 — Uranoplasty  (Esmarch 
and  Kowalzig). 


mucous  membrane  from  each  side  of  the  fissure  from  the  lip 
of  the  uvula  to  the  top  of  the  gap.  Make  a  free  incision 
"  along  the  alveolar  aspect  of  the  palate  "  close  to  the  teeth. 
Lift  up  the  strips  of  muco-periosteum  and  shift  them  toward 
the  cleft.  Sever  the  attachments  of  the  soft  palate  to  the 
posterior  border  of  the  hard  palate  and  extend  the  alveolar 
incision  well  backward.  This  incision  relieves  tension.  Sew 
up  with  wire  ;  twist  each  wire  and  cut  each  wire,  leaving  an  end 
one-eighth  of  an  inch  long.  This  procedure  causes  the  child 
to  keep  his  tongue  from  the  suture-line.  For  the  first  twenty- 
four  hours  give  only  water,  and  after  this  feed  with  beef 
jelly  and  liquids. 

When  feeding  is  begun  attempt  irrigation  or  spraying  if 
it  does  not  alarm  the  child.     In  a  day  or  two  the  patient  can 


Fig.  195. — Removal  of  lower  lip  and  cheilo-        Fig.  196. — Suturing  in  cheiloplasty  (Es- 
plasty  (Esmarch  and  Kowalzig).  march  and  Kowalzig). 

take  sweetened  orange-juice,  custard-pudding,  finely  sieved 

'  Lancet,  Jan.  4,  1896. 


6l8  MODERN  SURGERY. 

meat  or  chicken.  The  best  fluid  for  irrigation  is  Condy's 
fluid  or  mild  carboHc  acid. 

Get  the  child  out  in  the  air  a  day  or  two  after  the  opera- 
tion and  keep  it  out  all  day.  (The  entire  article  of  Mr. 
Owen's  will  well  repay  a  careful  reading.) 

Cancer  of  the  Lip. — Epithelioma  is  common  in  the  lower 
lips  of  males  (page  233).  In  most  instances  it  may  be  re- 
moved by  a  V-shaped  incision,  the  wound  being  closed  as  in 
harelip.  The  glands  from  beneath  the  jaw,  whether  enlarged 
or  not,  should  always  be  removed.  If  the  growth  is  exten- 
sive, the  entire  lower  lip  is  removed  and  cheiloplasty  is  per- 
formed to  replace  the  lip  (Figs.  195,  196). 

Tongue-tie  is  a  congenital  shortness  of  the  frenum.  The 
tongue  cannot  be  protruded  beyond  the  incisor  teeth.  Swal- 
lowing is  interfered  with,  and  later  in  life  articulation  is 
impeded.  To  treat  tongue-tie,  tear  up  the  frenum  with  the 
thumb-nail.  If  this  fails,  catch  the  frenum  in  the  slit  in  the 
handle  of  a  grooved  director,  push  the  director  toward  the 
base  of  the  tongue,  and  divide  the  frenum  with  scissors 
curved  on  the  flat  and  pointed  toward  the  director. 

Ranula  is  a  dilatation  of  one  of  the  ducts  of  the  mucous 
glands  of  Nuhn  and  Blandin.  These  glands  lie  on  each  side 
of  the  frenum  of  the  tongue.  It  was  long  thought  that  a 
ranula  arose  from  obstruction  in  the  duct  of  the  sublingual 
gland,  A  ranula  appears  upon  the  floor  of  the  mouth  on 
one  side  and  pushes  the  tongue  toward  the  opposite  side. 
The  contents  of  a  ranula  resemble  mucus  or  saliva.  The 
treatment  of  ranula  is  by  excision  of  a  portion  of  the  cyst- 
wall  and  cauterization  of  the  interior  with  pure  carbolic  acid 
or  with  15  minims  of  a  solution  consisting  of  10  parts  of 
tincture  of  iodin,  10  parts  of  water,  and  i  part  of  iodid  of 
potassium  ;  or  by  cutting  a  flap  from  the  cyst-wall  and  stitch- 
ing it  aside  so  as  to  keep  a  permanent  opening.. 

Partial  Removal  of  the  Tongue. — This  has  been  practised 
many  times  for  cancer  of  the  anterior  portion  of  this  organ. 
In  malignant  disease,  if  one  side  of  the  tongue  alone  is  in- 
volved, remove  one-half  of  the  organ ;  if  both  sides  of  the 
tongue  are  involved,  remove  the  organ  entirely.  Even  in 
partial  excision  for  malignant  disease  remove  all  of  the 
glands  from  the  submaxillary  triangle  of  the  diseased  side, 
even  when  they  are  not  apparently  involved.  This  is  the 
only  chance  for  the  patient's  cure,  as  these  glands  are  in- 
volved long  before  the  involvement  is  obvious  to  touch. 

In  performing  the  operation  of  partial  excision  introduce  a 
mouth  gag,  place  a  silk  ligature  on  each  half  of  the  tip  of 


DISEASES  AND  INJURIES  OF  THE  DIGESTIVE  TRACT.    619 


the  tongue,  and  draw  the  tongue  out  of  the  mouth  (Barker). 
Split  the  tongue  back  in  the  middle  line  with  the  scissors, 
and  loosen  the  cancerous  side  from  the  floor  of  the  mouth 
and  side  of  the  mouth.  Pass  a  stout  silk  ligature  through 
the  base  of  the  tongue  posterior  to  the  cancer.  Draw  the 
organ  out  and  cut  off  the  diseased  side  in  front  of  the  liga- 
ture but  back  of  the  disease.  Tie  the  vessels,  remove  the 
constricting  and  traction  threads,  and  treat  subsequently  as 
in  cases  of  complete  removal. 

Complete  Removal  of  the  Tongue  (Kocher's  Method). — 
Kocher  used  to  employ  a  preliminary  tracheotomy  in  tongue- 
excision,  but  the  Trendelenburg  position  renders  this  proced- 
ure unnecessary  so  far  as  hemorrhage  is  concerned.  Always 
clean  the  mouth  well.  The  instruments  required  are  a 
scalpel,  retractors,  a  dry  dissector,  hemostatic  and  dissecting- 
forceps,  a  tenaculum,  aneurysm-needle,  tenaculum-forceps, 
needles,  sutures,  and  scissors. 
In  this  operation  the  patient  is 
placed  in  the  Trendelenburg 
position,  the  surgeon  standing  by 
the  affected  side.  Chloroform 
is  given.  An  incision  is  made 
from  behind  the  lobe  of  the  ear, 
along  the  anterior  edge  of  the 
sternocleidomastoid  to  about 
the  middle  of  the  margin  of  this 
muscle.  From  this  point  the 
incision  is  carried  to  the  hyoid 
bone  and  then  to  the  symphysis 
menti,  along  the  anterior  belly 
of  the  digastric  muscle  (Fig.  197). 

The  flap  is  dissected  and  turned  up ;  the  facial  and  lingual 
arteries  are  ligated  ;  "  the  submaxillary  fossa  is  evacuated  " 
(Treves) ;  the  sublingual  and  submaxillar}'  glands  are  re- 
moved ;  the  mylohyoid  muscle  is  divided ;  the  mucous  mem- 
brane is  incised  close  to  the  jaw,  and  the  tongue,  caught  with 
tenaculum-forceps,  is  drawn  through  the  opening.  The  tongue 
is  split  in  the  middle  with  scissors,  and  the  near  half  is  re- 
moved. Arrest  bleeding.  If  the  whole  tongue  requires  re- 
moval, perform  a  set  ligation  of  the  lingual  artery  of  the  oppo- 
site side.  Some  surgeons  stitch  the  mucous  membrane  of 
the  stump  to  the  mucous  membrane  of  the  floor  of  the 
mouth  ;  others  employ  no  sutures.  Kocher  does  not  suture 
his  skin-wound ;  many  surgeons  do,  and  employ  drainage- 
tubes.     Keen  advises  closing  the  floor  of  the  mouth,  if  pos- 


FiG.  197. — Kocher's   excision  of  tongue 
(Esmarch  and  Kowalzig). 


620  MODERN  SURGERY. 

sible.  Some  hours  after  the  operation,  when  oozing  has 
ceased,  dust  the  mouth-wound  with  iodoform.  The  patient, 
as  soon  as  possible,  is  propped  up  in  bed,  and  he  must  not 
swallow  the  discharges  if  it  can  be  avoided.  The  mouth, 
every  half  hour,  is  sprayed  out  with  peroxid  of  hydrogen 
and  washed  with  a  carbolic  solution  ( i  :  60).  Every  three 
hours  after  washing  the  floor  of  the  mouth  and  the  stump, 
dry  with  absorbent  cotton  and  dust  with  iodoform.  For 
twenty-four  hours  after  the  operation  nothing  is  given  by 
the  mouth  except  a  little  cracked  ice,  the  patient  being  fed 
per  rectum.  At  the  end  of  twenty-four  or  forty-eight  hours 
some  liquid  food  is  given  from  a  feeding-cup.  The  patient  will 
soon  learn  to  swallow;  but  if  he  cannot  swallow  easily,  feed 
from  a  tube.  Treves,  in  his  clear  and  positive  directions  for 
after-treatment,  states  that  nutrient  enemata  are  to  be  con- 
tinued until  sufficient  nourishment  is  taken  by  the  mouth ; 
that  the  mouth  should  be  flushed  out  by  irrigation,  and  must 
be  washed  immediately  after  taking  food ;  that  morphin  is  to 
be  avoided ;  and  that  the  patient  can  usually  leave  the  hos- 
pital in  from  seven  to  ten  days.  Whitehead  removes  the 
entire  tongue  from  within  the  mouth  by  the  use  of  scissors. 
He  passes  a  ligature  through  the  tip,  cuts  the  frenum,  draws 
the  tongue  strongly  forward  and  separates  by  a  series  of  clips 
with  the  scissors.  The  lingual  arteries  are  tied  as  cut.  "  The 
stump  should  be  kept  under  control,  as  regards  hemorrhage, 
by  a  stout  silk  ligature  passed  through  the  remains  of  the 
glosso-epiglottidean  fold  and  retained  for  twenty -four  hours."  ^ 

Heath  has  shown  that  if  the  forefinger  be  passed  to  the  epi- 
glottis and  used  to  "  hook  forward  "  the  hyoid  bone,  the  lin- 
gual arteries  are  stretched  and  portions  of  the  tongue  can  be 
removed  almost  without  bleeding.  After  Whitehead's  opera- 
tion always  remove  the  glands  from  the  submaxillary  triangles. 

Stricture  of  the  Esophag-us. — Fibrous  or  cicatricial  strict- 
ure is  due  to  traumatism,  chronic  inflammation,  syphilis, 
tuberculosis,  ulcer,  prolonged  vomiting,  variola,  gout,  or  to 
swallowing  a  corrosive  substance  or  a  boiling  liquid.  It  is 
commonest  in  the  young,  and  is  apt  to  be  situated  opposite 
the  cricoid  cartilage  at  the  tracheal  bifurcation  or  near  the 
cardiac  end.  Cicatricial  strictures  are  usually  single,  but  may 
be  multiple.  Stricture  following  impaction  of  a  foreign  body 
is  located  at  the  seat  of  impaction  unless  the  tube  has  been 
injured  by  efforts  at  extraction,  in  which  case  multiple  strict- 
ures may  exist  (Maylard).  Strictures  which  result  from  swal- 
lowing boiling  fluid  or  corrosive  liquid  are  usually  very  exten- 

^  American  Text-book  of  Surgery. 


DISEASES  AND  INJURIES  OF  THE  DIGESTIVE  TRACT.   62 1 

sive,  and  may  be  multiple.  Syphilitic  stenosis  is  due  to  the 
healing  of  a  gummatous  ulceration,  but  there  is  nothing  char- 
acteristic of  this  kind  of  stenosis  (Maylard).  Tubercular 
stenosis  is  extremely  rare.  Cancerous  stricture  occurs  in  those 
beyond  middle  life,  and  is  far  more  common  in  men  than  in 
women  (see  Morell  Mackenzie).  Any  portion  of  the  canal 
may  be  attacked,  but  the  central  portion  is  least  often  the 
seat  of  cancer  (Maylard,  Butlin).  The  majority  of  cancers 
of  the  esophagus  are  epitheliomata,  but  scirrhus,  encepha- 
loid,  or  colloid  may  occur.  Cancer  soon  ulcerates  and 
involves  adjacent  parts  by  infiltration.  The  deep  cervical 
and  posterior  mediastinal  glands  are  involved  (Maylard). 
Spasmodic  or  hysterical  stricture,  or  esophagismus,  which  is 
commonest  in  women,  is  associated  with  the  stigmata  of 
hysteria,  and  especially  with  globus  (a  sense  as  of  a  ball 
rising  in  the  throat) ;  a  bougie  held  against  it  is  only  tem- 
porarily obstructed.  The  contraction  arises  suddenly,  and 
one  passage  of  a  bougie  often  causes  it  to  disappear. 

Symptoms  of   Cicatricial  Stenosis.  —  The    condition    may 


Fig.  198. — Esophageal  instruments :  a,  b,  forceps  ;  c,  horsehair  probang ;  d,  coin-catcher ; 
E,  esophageal  bougie. 

occur  at  any  age.     The  chief  symptom  is  difficulty  in  swal- 
lowing, at  first  slight,  but  becoming  more  and  more  pro- 


622  MODERN  SURGERY. 

nounced  until  swallowing  is  almost  or  quite  impossible.  The 
dysphagia  is  first  manifested  to  dry  solids,  then  to  all  solids, 
and  finally  to  liquids.  In  some  cases  vomiting  occurs  after 
swallowing.  If  the  stricture  is  high  up,  the  vomiting  is  almost 
immediate ;  if  it  is  low  down,  the  vomiting  is  delayed,  especially 
if  the  canal  is  dilated  above  the  stricture.  From  time  to  time 
the  patient  vomits  independently  of  taking  food,  the  ejected 
matter  being  saliva.  Vomited  matter  is  not  bloody.  The  pa- 
tient feels  weak  and  hungry,  becomes  exhausted  and  ema- 
ciated, and  suffers  from  flatulence,  gastralgia,  and  constipation. 

There  is  occasionally  slight  uneasiness  or  even  pain  in  the 
region  of  the  stricture,  possibly  "  about  the  epigastrium  or 
between  the  shoulder-blades"  (Maylard).  The  stricture  may 
be  located  with  a  bougie.  The  history  of  the  case  is  of  much 
importance  in  diagnosis.  Inquire  about  impaction  of  a  foreign 
body,  or  swallowing  of  acids,  alkalies,  or  boiling  fluids ;  ex- 
amine for  evidence  of  syphiHs.  If  there  is  no  history  of  in- 
jury or  syphilis,  and  the  patient  is  over  forty  years  of  age,  the 
indications  point  to  cancer  rather  than  cicatricial  stenosis. 
The  easy  passage  of  a  bougie  when  the  patient  is  anesthet- 
ized shows  that  spasm  is  the  cause,  and  not  organic  disease. 
Narrowing  due  to  external  pressure  is  marked  by  positive 
symptoms  of  the  causative   disease.^ 

Treatment. — Gradual  dilatation  through  the  mouth  is  a 
method  employed  for  at  least  a  time  in  almost  every  case. 
Begin  with  the  largest  bougie  which  will  easily  pass.  Warm 
the  bougie,  oil  it,  pass  it  gently,  and  hold  it  in  position  for 
several  minutes,  prolonging  the  time  of  retention  of  the 
bougie  as  treatment  progresses.  Pass  an  instrument  every 
second  or  third  day,  gradually  increasing  the  size. 

Symonds  advocates  the  insertion  of  a  tube  through  the 
stricture  and  leaving  it  in  place  until  dilatation  is  distinct,  and 
then  replacing  the  tube  with  a  larger  instrument.  The 
patient  is  fed  through  the  tube.  Gradual  dilatation  from  below 
has  been  practised  in  cases  where  a  bougie  could  not  be 
passed  from  the  mouth.  A  gastrostomy  is  performed  and 
after  the  fistula  has  become  sound  the  patient  is  made  to 
swallow  "a  shot  to  which  is  attached  a  silk  thread"  (May- 
lard). The  silk  thread  is  brought  out  through  the  fistulous 
orifice  and  is  attached  to  a  bougie,  and  the  dilating  instru- 
ment is  pulled  up  through  the  esophagus.  Forcible  dilata- 
tion can  be  employed  through  the  mouth  or  through  a 
gastrotomy  opening  by  means  of  bougies,  tents,  or  divulsing 
instruments.    Electrolysis  is  used  by  Fort  and  others.    Some 

^  See  the  excellent  article  in  Maylard's  Surge7'y  of  the  Alimentary  Canal. 


DISEASES  AND  INJURIES  OF  THE  DIGESTIVE  TRACT.    623 

surgeons  perform  internal  esophagotomy  through  the  mouth 
with  a  special  instrument ;  some  advocate  external  esopha- 
gotomy ;  some  incise  the  esophagus  above  the  stricture  and 
pass  bougies  from  the  wound  through  the  region  of  stenosis. 

Abbe  of  New  York  devised  a  very  ingenious  operation. 
He  performs  a  gastrotomy,  passes  a  conical  rubber  bougie 
from  the  mouth  into  the  stomach  or  from  the  stomach  into 
the  mouth,  ties  a  piece  of  braided  silk  to  the  bougie,  with- 
draws the  instrument  and  leaves  the  silk  in  place.  One  end 
of  the  silk  emerges  from  the  mouth  and  the  other  end  from 
the  gastrotomy  wound.  In  some  cases  he  opens  the  stomach 
and  also  opens  the  esophagus  above  the  stricture,  one  end  of 
the  string  comes  out  of  the  esophagotomy  wound  and  the 
other  end  out  of  the  gastrotomy  wound.  The  string  is  used 
as  a  string  or  bow-saw,  the  stricture  is  divided,  the  silk  is 
withdrawn,  full-sized  bougies  are  passed,  and  the  wound  or 
wounds  are  sutured.  In  very  bad  cases  gastrostomy  is  per- 
formed to  keep  the  patient  from  starving. 

Svinptonis  of  Cancerous  Stenosis. — The  patient  is  over  forty 
years  of  age,  is  usually  a  male,  and  presents  the  same  diffi- 
culty of  swallowing  met  with  in  cicatricial  stenosis.  The 
vomited  matter  is  apt  to  contain  blood,  the  use  of  the  bougie 
causes  bleeding ;  there  are  generally  decided  pain  and  very 
great  emaciation.  The  seat  of  obstruction  is  located  by 
the  bougie  and  by  listening  over  the  spine  while  the  patient 
is  attempting  to  swallow  water.  The  stomach  is  the  seat  of 
pain ;  the  mouth  is  dry  and  there  is  often  great  thirst.  As  the 
disease  infiltrates  the  involvement  of  adjacent  regions  pro- 
duces other  symptoms.  Dyspnea  may  result  from  tracheal 
pressure.     Pleuritis,  pericarditis,  or  pneumonia  may  arise. 

Treatment. — The  disease  is  of  necessity  fatal,  and  treatment 
is  only  palliative.  Successful  excision  is  not  feasible.  Feed 
upon  soft,  bland  diet  in  small  quantities  given  frequently. 
When  trouble  is  experienced  even  with  such  food,  pass  a 
bougie  every  third  or  fourth  day.  When  the  patient  be- 
comes entirely  unable  to  swallow  soft  food  we  may  insert 
a  Symond's  tube  or  do  an  esophagostomy  (if  this  can 
be  performed  below  the  stricture),  or  perform  gastrostomy. 
In  every  doubtful  case  of  esophageal  stricture  giv^e  a  course 
of  iodid  of  potassium  before  performing  any  operation  (the 
younger  Gross). 

Diverticula  of  the  Esophagns, — Maylard  tells  us  that 
these  pouches  may  be  due  to  one  of  four  causes — they  may 
be  congenital ;  may  be  due  to  stricture ;  may  be  caused  by 
pressure  from  within,  upon  a  weak  spot  of  the  wall ;  may 


624  MODERN  SURGERY. 

be  due  to  traction  from  without,  by  the  heahng  and  con- 
traction of  an  area  of  inflammation. 

Symptoms. — When  the  diverticulum  is  in  the  neck  a  lump 
forms  during  deglutition,  and  this  lump  may  be  obliterated 
by  pressure.  Food  will  pass  into  the  stomach  only  when 
the  diverticulum  is  full.  A  bougie  cannot  be  passed  unless 
the  pouch  is  full  of  food,  at  which  time  it  may  pass  or  may 
not.  This  latter  symptom,  the  variability  in  the  passage  of 
the  bougie,  is  the  evidence  reUed  on  for  diagnosis  in  infra- 
thoracic  diverticula.  By  listening  with  a  stethoscope  fluid 
may  be  heard  to  pass  into  the  pouch. 

Treatme7it. — Extirpation  and  suture,  as  performed  by  von 
Bergmann,  Hearn,  and  others. 

Injuries  of  the  Esophag-us. — Injuries  of  the  internal  sur- 
face are  more  common  than  injuries  from  without.  Burns 
and  scalds  are  among  these  injuries.  Wounds  may  be  in- 
flicted by  foreign  bodies.  These  injuries  cause  pain  on  swal- 
lowing. A  severe  injury  causes  bleeding,  the  blood  being 
both  coughed  up  and  vomited.  A  severe  wound  may  involve 
a  large  vessel  and  cause  violent  or  fatal  hemorrhage.  If  the 
bronchus  or  trachea  is  involved  there  will  be  "  cough  and 
expectoration  of  blood,  mucus,  and  food  "  (Maylard).  The 
pleural  or  pericardiac  sacs  may  be  perforated. 

Treatment. — Feed  purely  by  the  rectum.  Give  morphin 
hypodermatically.  Do  not  feed  by  the  mouth  for  ten  days, 
and  even  then  give  only  fluid  food  and  jelly.  Symptoms  are 
met  as  they  arise.  In  burns  by  caustics  administer  the  anti- 
dote ;  give  large  draughts  of  water  and  wash  out  the  stomach. 

Injuries  of  the  esophag-us  from  outside,  ■without  in- 
volvement of  other  structures,  are  rare.  Esophageal  in- 
juries, as  a  rule,  are  associated  with  serious  damage  to  adja- 
cent structures.  These  injuries  may  be  due  to  stabs  or  to 
bullets.  Besides  the  obvious  external  signs  of  the  injury 
there  will  be  difficulty  in  swallowing,  cough,  bloody  expec- 
toration or  vomiting ;  and  mucus  or  the  contents  of  the 
stomach  may  run  out  of  the  wound. 

Treatment. — Suture  the  wound,  and  feed  by  the  rectum  for 
ten  days. 

Foreign  Bodies  Lodged  in  the  Esophag-us. — These  acci- 
dents occur  especially  to  children  and  lunatics,  and  women 
are  more  apt  to  suffer  from  them  than  are  men.  An  elaborate 
list  of  bodies  which  have  been  swallowed  will  be  found  in 
Poulet's  elaborate  treatise.  There  are  three  spots  where  a 
foreign  body  is  especially  apt  to  lodge — viz.  opposite  the 
cricoid  cartilage,  at  the  level  of  the  diaphragm,  and  at  the 


DISEASES  AND  INJURIES  OF  THE  DIGESTIVE  TRACT.    625 

point  where  the  left  bronchus  crosses  the  gullet.     Small  and 
sharp  bodies  may  lodge  anywhere. 

Symptoms. — The  symptoms  are  variable ;  if  the  body  is 
large,  there  will  be  pain  and  difficulty  in  swallowing,  and,  in 
some  cases,  dyspnea  from  pressure  upon  the  trachea  or 
bronchus.  Death  may  result  from  asphyxia.  In  some  other 
cases  the  symptoms  are  very  slight.  If  the  body  is  sharp, 
there  will  be  hemorrhage  and  severe  pain.  The  blood  may 
be  hawked  up,  or  may  be  swallowed  and  vomited.  A  patient 
may  grow  accustomed  to  a  foreign  body  and  cease  to  notice 
it ;  but,  on  the  contrary,  the  foreign  body  may  produce  in- 
flammation, and  even  may  ulcerate  into  the  windpipe,  the 
pleura,  the  pericardium,  or  the  aorta.  In  many  cases  of  im- 
paction a  patient  makes  violent  efforts  to  hawk  it  up,  and 
produces  aphonia.  There  may  be  violent  retching.  Even 
after  a  foreign  body  has  been  removed  by  swallowing  or 
otherwise  a  sensation  is  apt  to  remain  as  if  it  were  still 
lodged.  The  diagnosis  is  made  by  the  history,  the  detection 
of  the  body  by  external  manipulation,  by  feeling  it  with  an 
esophageal  bougie,  and,  if  bone  or  metal,  seeing  it  with  the 
fluoroscope  or  obtaining  a  skiagraph. 

Treatmait. — The  surgeon  should  find  out  if  possible  the 
size,  shape,  weight,  and  nature  of  the  foreign  body,  and  locate 
its  point  of  impaction.  In  metal  bodies  or  bone  the  exact 
point  of  lodgement  is  determined  by  the  Jf-rays.^  An 
anesthetic  is  usually  necessary  in  a  child,  a  nervous  woman, 
or  a  lunatic,  and  is  sometimes  necessary  in  a  man.  If  the  for- 
eign body  is  soft,  external  manipulation  may  succeed  in  alter- 
ing its  shape,  so  that  it  may  be  swallowed  or  ejected.  If  the 
foreign  body  is  hard,  external  manipulation  may  shift  its  posi- 
tion. It  is  usually  impossible  to  reach  the  foreign  body 
through  the  mouth  by  means  of  the  fingers  (when  the  body 
is  in  the  rear  of  the  pharynx  it  may  be  pulled  forward  or 
pushed  down).  Sharp  foreign  bodies  may  be  entangled  and 
carried  down  when  the  patient  eats  mush,  bread,  or  boiled 
potatoes.  The  administration  of  emetics  is  an  old  plan 
which  occasionally  succeeds,  but  which  is  often  unsafe. 
It  is  not  to  be  advised.  Maylard  says  that  when  a 
mass  of  food  is  impacted  it  is  occasionally  possible  to 
soften  and  disintegrate  the  mass  by  administering  a  mix- 
ture containing  pepsin.  The  horsehair  probang  is  a  very 
useful  instrument  (Fig.  198,  c).  It  may  be  used  to  push  a  body 
downward  into  the  stomach,  or  to  catch  the  body  and  pull  it 
up.    When  this  instrument  is  withdrawn  it  opens  like  an  um- 

1  See  cases  of  White,  Keen,  Alfred  Wood,  Maclntyre,  and  others. 
40 


626  MODERN  SURGERY. 

brella.  Maylard  quotes  Morris  Richardson  to  the  effect  that 
in  an  adult  the  diaphragmatic  opening  is  about  fourteen  and 
one-half  inches  from  the  incisor  teeth,  a  point  to  be  remem- 
bered in  deciding  whether  to  push  down  or  pull  up  the  im- 
pacted article.  Esophageal  forceps  (Fig.  198,  a,  B)are  valuable 
in  some  cases.  The  coin-catcher  (Fig.  198,  d)  is  a  useful  in- 
strument. Crequy's  plan  of  removal  is  to  take  a  tangled  mass 
of  threads,  tie  a  stout  piece  of  string  about  the  middle  of  it, 
coat  it  with  sugar,  and  have  the  patient  swallow  it.  It  may 
pass  the  foreign  body ;  if  it  does  so,  on  withdrawal  it  may 
entangle  the  object  and  extract  it.  To  remove  a  fish-hook 
with  line  attached,  the  following  plan  may  prove  successful : 
stick  the  line  into  a  metal  catheter,  carry  the  catheter  down 
to  the  hook,  and  push  the  hook  out.  If  efforts  at  extrac- 
tion through  the  mouth  are  futile,  it  may  be  necessary  to 
perform  esophagotomy.  The  cut  is  made  on  the  left  side, 
between  the  trachea  and  larynx  in  front  and  the  carotid 
sheath  behind,  the  center  of  the  incision  being  opposite  the 
cricoid  cartilage.  After  the  foreign  body  is  extracted  the 
mucous  membrane  is  sutured  with  chromic  catgut,  and  the 
superficial  structures  are  closed  with  silkworm-gut.  The 
patient  is  fed  by  the  rectum  for  eight  or  ten  days.  In  cases 
where  the  impaction  is  low  down  gastrotomy  is  performed. 
In  White's  case  of  jackstone  in  the  gullet  gastrotomy  was 
performed.  A  string  was  tied  about  some  rolls  of  gauze,  the 
string  was  passed  by  mean^  of  a  whalebone  from  the  stomach 
into  the  mouth,  and  the  body  was  entangled  and  drawn  out. 

XXVII.  DISEASES  AND  INJURIES  OF  THE  ABDOMEN. 

Contusion  of  the  Abdominal  Wall  without  Injury 

of  Viscera. — In  some  cases  of  contusion  of  the  abdominal 
wall  only  the  parietes  are  contused ;  in  other  cases  the  viscera 
or  the  abdominal  tissues  are  injured.  Contusion  may  involve 
the  skin  alone,  or  may  involve  the  skin,  muscles,  and  perito- 
neum. In  simple  contusion  there  is  considerable  shock  if  the 
injury  is  severe.  There  is  pain,  increased  by  respiration, 
motion,  pressure,  and  attempts  at  urination  or  defecation. 
When  tenderness  appears  some  days  after  the  accident  there 
is  deep-seated  injury.  Extensive  ecchymosis  may  appear.  In 
even  a  severe  case  there  may  be  no  discoloration,  and  in 
even  a  slight  case  there  may  be  much  discoloration.  There 
is  great  ecchymosis  in  anemic  persons,  victims  of  hemi- 
plegia, in  obese  individuals,  opium-eaters,  and  drunkards. 
In  severe  cases  the  tissues  are  pulpefied  and  sloughing  inevi- 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       627 

tably  ensues.  Abscess  occasionally  follows  contusion.  The 
prognosis  after  abdominal  contusion  is  always  uncertain.  In 
treating  simple  contusion  place  the  patient  at  rest  in  a  supine 
position,  with  the  thighs  flexed  over  a  pillow ;  obtain  reac- 
tion from  the  shock ;  and  give  morphin  for  pain.  After  the 
patient  has  reacted  it  is  advisable  to  place  an  ice-bag  ov^er 
the  injury  from  time  to  time,  and  in  the  intervals  of  its  appli- 
cation use  lead-water  and  laudanum  locally.  If  much  blood 
is  extravasated,  aspirate  and  apply  a  binder.  After  twenty- 
four  hours  apply  intermittent  heat  by  the  hot-water  bag, 
employ  an  ointment  of  ichthyol,  and  move  the  bowels,  if 
necessary,  by  salines.  Regard  every  contusion  as  serious, 
and  watch  carefully  for  the  development  of  signs  of  internal 
hemorrhage  or  visceral  injury. 

Muscular  Rupture  from  Contusion. — In  this  injury  there 
are  severe  shock  and  pain  (increased  by  respiration  and  move- 
ment). Separation  between  the  fibers  of  the  muscle  is  dis- 
tinct at  first,  but  it  is  soon  masked  by  effusion  of  blood. 
Such  injuries  may  cause  death,  or  they  may  lead  to  hernia. 
The  rectus  is  the  muscle  most  apt  to  rupture.  The  rupture 
is  due  to  sudden  contraction  rather  than  to  a  blow. 

The  treatment  is  the  same  as  for  simple  contusion.  Al- 
ways apply  a  binder.  A  hernia  is  returned  and  a  compress 
is  applied  over  the  opening  through  which  it  emerged.  If 
strangulation  occurs,  operate  at  once. 

Injuries  with  Damage  to  the  Peritoneum  or  the 
Viscera. — Rupture  of  the  Peritoneum. — The  peritoneum 
may  be  involved  in  an  abdominal  contusion.  It  may  rupt- 
ure even  without  any  visceral  injury  or  muscular  contusion. 
The  uterine  peritoneum,  the  parietal  peritoneum,  the  visceral 
peritoneum,  or  the  mesentery  may  rupture.  Rupture  of 
peritoneum  causes  intra-abdominal  hemorrhage  (page  627). 
The  treatment  consists  in  opening  the  abdomen,  arresting 
the  hemorrhage,  and  bringing  about  reaction. 

An  injury  to  the  peritoneum  creates  a  point  of  least  re- 
sistance, and  at  such  a  point  peritonitis  may  develop.  The 
peritonitis  is  usually  local,  but  may  become  general.  After 
any  severe  intra-abdominal  injury  the  symptoms  of  perito- 
neal shock  appear  (peritonism),  and  the  patient  may  rapidly 
die.  In  the  condition  of  peritonism  the  temperature  is  sub- 
normal ;  the  extremities  are  cold ;  the  face  is  pallid  and 
sunken ;  the  pulse  is  small,  weak,  and  very  frequent ;  the 
respiration  is  shallow  and  sighing  ;  there  is  great  thirst ;  the 
patient  is  restless  and  tosses  about.  Vomiting  almost  always 
occurs.     In  some  cases  there  is  regurgitation  rather  than 


628  MODERN  SURGERY. 

vomiting.  The  abdomen  is  the  seat  of  a  violent,  persistent 
pain.  The  patient  is  fearful  of  impending  death.  As  the 
symptoms  develop  in  a  grave  case  they  will  point  to  one  of 
two  conditions,  hemorrhage  or  peritonitis. 

In  intra-abdominal  hemorrhage  the  subnormal  temperature 
and  other  evidences  of  shock  persist.  Vomiting  ceases,  but 
nausea  exists.  The  patient  is  uncontrollably  restless  and  tosses 
about  in  bed.  The  thirst  is  great.  The  abdomen  is  not  rigid. 
Fainting-spells  occur.  Blood-examination  shows  a  great 
fall  in  the  percentage  of  hemoglobin.  Percussion  shows  the 
existence  of  an  effusion  which  alters  its  position  as  the 
patient's  position  is  altered,  and  which  gradually  increases 
in  amount.  Dulness  is  first  met  with  in  the  loins.  Rectal 
or  vaginal  examination  may  aid  in  diagnosis.  If  peritonitis 
develops,  the  vomiting  becomes  worse,  the  pain  intensifies, 
and  the  abdomen  grows  rigid  and  distended. 

Rupture  of  the  Stomach  without  Bxtemal  Wound. 
— The  usual  cause  of  rupture  is  a  violent  blow,  although  the 
accident  may  happen  in  washing  out  the  stomach.  Rupture 
is  more  apt  to  occur  when  the  stomach  is  distended  with  food 
than  when  it  is  empty.  The  rupture  may  be  partial,  the  perito- 
neal coat  not  being  torn.  The  rupture  may  be  complete.  The 
region  of  the  pylorus  is  most  apt  to  be  lacerated.  The  symp- 
toms of  rupture  are  collapse,  severe  pain  over  the  entire  abdo- 
men, great  thirst,  excessive  tenderness,  especially  over  the  epi- 
gastric region,  occasionally  vomiting,  the  vomited  matter  being 
usually,  but  not  invariably,  bloody ;  tympanitic  distention  and 
muscular  rigidity  coming  on  after  a  few  hours.  Gas  may  enter 
the  abdominal  cavity  and  cause  the  disappearance  of  liver-dul- 
ness,  but  liver-dulness  can  be  abolished  by  great  intestinal  dis- 
tention. After  incomplete  rupture  local  peritonitis  is  frequent ; 
in  complete  rupture  the  escape  of  food  into  the  peritoneal 
cavity  causes  septic  peritonitis.  To  diagnosticate  between 
complete  and  incomplete  rupture,  endeavor  to  distend  the 
viscus  with  hydrogen  gas  :  in  incomplete  rupture  the  contour 
of  the  dilated  stomach  can  be  made  out  upon  the  surface ; 
in  complete  rupture  the  viscus  cannot  be  distended  and  the 
gas  passes  into  the  peritoneal  cavity,  producing  the  physical 
signs  of  tympanites  (Senn).  The  treatment  in  complete  rupt- 
ure is  as  follows :  if  signs  of  hemorrhage  are  absent,  en- 
deavor to  bring  about  reaction  before  operating.  If  these 
signs  are  present,  operate  at  once.  Open  the  abdomen  ;  if 
the  rent  is  not  visible,  find  it  by  inflating  the  stomach  with 
hydrogen  ;  flush  out  the  stomach  and  the  peritoneal  cavity 
with  hot  salt-solution  ;   sew  up  the  stomach-wound  with  a 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       629 

double  row  of  silk  sutures,  the  first  row  being  buried  and 
including  the  muscular  coat  and  mucous  coat,  the  second 
row  being  Halsted  sutures  ;  drain ;  close  the  wound  in  the 
parietes  with  silkworm-gut ;  feed  by  the  rectum  for  four  days, 
and  then  begin  the  administration  of  a  very  little  food  by  the 
mouth.  In  incomplete  rupture  the  danger  is  perforation. 
The  patient  is  put  to  bed,  and  after  reaction  has  taken  place, 
is  fed  by  the  rectum  for  several  days,  and  morphin  is  given 
hypodermatically. 

Rupture  of  the  Intestine  without  Kxternal  Wound. 
— The  symptoms  of  this  injury  are  profound  shock,  tympan- 
ites, and  pain,  rapidly  followed  by  peritonitis  if  the  patient 
survives.  Vomiting  comes  on  soon  after  the  accident,  the 
vomited  matters  being  possibly  at  first  bloody  and  then 
stercoraceous.  The  respiration  is  thoracic,  the  tongue  is  dry, 
and  great  thirst  exists.  The  pulse,  which  is  slow  at  first, 
becomes  small  and  rapid.  A  high-tension  pulse  accompanies 
tympanites,  because  the  distention  of  the  bowel  greatly 
decreases  the  amount  of  blood  in  its  coats,  and  thus  in- 
creases the  amount  of  blood  in  the  rest  of  the  system.  Any 
portion  of  the  intestine  may  rupture,  but  the  ileum  is  most 
liable  to  this  accident.  Blood  in  the  stools  rarely  appears 
early  enough  to  be  of  diagnostic  value.  The  escape  of  gas 
into  the  peritoneal  cavity  may  cause  disappearance  of  normal 
liver-dulness.  By  anesthetizing  the  patient  hydrogen  gas 
insufflated  into  the  rectum  will  come  from  the  mouth  if 
there  is  no  perforation  in  the  stomach  or  the  intestine ;  if  a 
perforation  exists,  tympanites  is  much  increased.  To  apply 
rectal  insufflation  of  hydrogen,  generate  the  gas  in  a  bottle 
by  means  of  zinc  and  sulphuric  acid,  catch  the  gas  in  a  large 
rubber  bag,  and  attach  the  tube  from  the  gas  reservoir  to  a 
tip  which  is  inserted  in  the  rectum.  Give  the  patient  ether 
to  relax  the  abdominal  muscles,  direct  an  assistant  to  press 
the  anal  margins  against  the  rectal  tip,  and  when  the  patient 
is  unconscious  turn  on  the  stopcock  and  press  upon  the 
reservoir  (Senn). 

Treatment. — If  symptoms  point  to  dangerous  hemorrhage 
operate  at  once,  otherwise  do  not  operate  until  reaction  has 
been  obtained.  Give  stimulants  by  the  rectum,  and  a  hypo- 
dermatic injection  of  morphin  and  atropin ;  asepticize  and 
anesthetize.  Perform  a  laparotomy ;  check  hemorrhage ; 
find  the  rent,  and  close  it  by  Helsted  sutures  if  possible. 
The  hydrogen  gas  test  of  Senn  will  discover  a  perforation. 
It  may  be  necessary  to  perform  an  end-to-end  approxima- 
tion  or  a   lateral    anastomosis.     Flush    out   the   abdominal 


630  MODERN  SURGERY. 

cavity  with  hot  saline  solution.  Some  surgeons  cleanse  the 
abdomen  by  wiping  with  gauze.  Finney  eviscerates,  wipes 
out  the  abdominal  cavity,  and  wipes  the  intestines  as  he 
restores  them.  Whatever  method  is  used  to  cleanse  the 
abdomen  remember  that  infectious  material  is  apt  to  accu- 
mulate between  the  liver  and  diaphragm  and  in  Douglas's 
pouch.     Drainage  is  to  be  used. 

"  In  abdominal  operations  it  is  frequently  imperatively 
necessary  that  the  large  intestine  be  recognized  with  cer- 
tainty or  the  small  bowel  be  positively  identified.  The  size 
of  the  tube  will  not  always  aid  in  this  recognition,  as  a  small 
intestine  may  be  distended  enormously  and  a  large  intestine 
may  be  contracted  to  the  size  of  a  finger  because  of  obstruc- 
tion above.  The  longitudinal  muscular  fibers  of  the  large 
bowel  are  accentuated  in  three  portions  ;  these  accentuations 
constitute  the  three  longitudinal  bands  which  begin  at  the 
cecum  and  terminate  at  the  end  of  the  sigmoid  flexure  of 
the  colon.  Each  band  is  composed  of  a  number  of  shorter 
bands,  the  shortness  of  these  constituent  bands  permitting 
the  sacculation  of  the  large  intestine.  Longitudinal  bands 
and  sacculation  are  not  met  with  in  the  small  gut,  their  pres- 
ence or  absence  being  a  means  of  identification  in  many 
cases ;  but  when  the  colon  is  much  distended  the  bands 
cannot  be  seen  distinctly  and  the  sacculation  disappears. 
From  the  large  intestine  only  spring  the  appendices  epiplo- 
icse  (small  overgrowths  of  fat  in  pouches  of  peritoneum), 
but  they  are  sometimes  not  well  marked  except  upon  the 
transverse  colon,  and  when  emaciation  exists  they  may 
almost  entirely  disappear.  The  relatively  fixed  position  of 
the  large  intestine  and  the  free  mobility  of  the  small  bowel 
are  important  points  of  distinction.  The  foregoing  indicates 
that  it  is  not  always  easy  to  distinguish  between  colon  and 
small  gut,  and  that,  according  to  old  rules,  it  may  often  be 
necessary  to  make  large  incisions,  to  see  as  well  as  feel,  and 
to  handle  a  large  extent  of  the  bowel.  Any  scrap  of  knowl- 
edge that  will  shorten  an  abdominal  operation,  that  will  per- 
mit of  as  certain  work  through  a  smaller  incision,  and  that 
will  diminish  handling  of  intraperitoneal  structures,  tends  to 
increase  the  chances  of  recovery.  For  these  reasons  the 
writer  suggests  a  method  of  bowel-identification  which  rests 
upon  the  facts  that  each  bowel  has  a  posterior  attachment, 
that  the  origin  of  the  attachment  differs  according  to  the 
bowel  it  supports,  that  a  single  finger  can  detect  the  origin 
of  the  peritoneal  support  of  any  section  of  the  bowel,  and, 
this  origin  being  known,  the  portion  of  the  bowel  it  supports 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       63 1 

is  with  certainty  deducible.  In  an  exploratory  operation,  for 
instance,  the  finger  comes  in  contact  with  the  bowel :  to  de- 
termine whether  it  is  a  large  or  a  small  bowel,  note  first  if 
the  structure  is  movable  or  is  firmly  fixed  ;  next,  pass  the 
finger  over  the  bowel  and  let  it  find  its  way  posteriorly.  If 
dealing  with  a  small  bowel,  the  finger  will  reach  the  origin 
of  the  mesentery  between  the  left  side  of  the  second  lumbar 
vertebra  and  the  right  sacro-iliac  joint ;  if  dealing  with  the 
large  bowel,  the  finger  will  reach  the  origin  of  the  meso- 
colon, or  the  point  where  the  colon  is  fixed  posteriorly  and 
to  the  side.'" 

Rupture  of  the  liver  may  be  caused  by  a  blow,  a  fall 
from  a  height,  or  the  concussion  of  a  railroad  collision.  Occa- 
sionally the  ends  of  fractured  ribs  are  driven  into  the  organ. 

The  symptoms  are  those  previously  set  forth  as  attending 
severe  intra-abdominal  injury  (page  627).  In  addition  there  are 
tenderness  over  the  liver,  and  often  pain  in  the  abdomen  and 
back.  As  a  rule,  the  signs  of  hemorrhage  are  present.  Sugar 
may  appear  in  the  urine.  The  respiration  is  much  embar- 
rassed. After  a  few  days  the  skin  may  itch  and  become 
jaundiced,  but  this  is  rare. 

In  these  cases  operate  at  once  if  hemorrhage  is  severe ; 
otherwise  operate  after  bringing  about  reaction.  Stop  bleed- 
ing in  the  liver  by  cautery,  by  suture,  or  by  packing.  In  a 
superficial  tear  introduce  sutures  of  catgut  or  silk.  In  a  deep 
tear  suture  the  liver  to  the  belly-wall,  pack  with  gauze,  and 
surround  the  rent  with  gauze. 

Rupture  of  the  Gall-bladder  and  the  Bile-ducts. 
— Rupture  of  the  gall-bladder  or  the  ducts  is  most  apt  to 
happen  from  injury  when  gall-stones  exist.  Peritonitis,  gen- 
eral or  local,  is  almost  certain  to  follow  such  ruptures.  Be- 
sides those  symptoms  common  to  all  severe  abdominal  injuries, 
there  is  often  intense  jaundice  (Deaver). 

Treatment. — Suture  the  laceration  or  make  a  biliary 
fistula. 

Rupture  of  the  Spleen. — The  spleen  may  be  dislocated 
as  well  as  ruptured.  Rupture  of  the  spleen  is  rare  without 
other  serious  injuries.  An  enlarged  spleen  is  far  more  liable 
to  injury  than  a  normal  organ.  The  usual  symptoms  of 
abdominal  injury  are  present.  In  addition  there  are  pain  over 
the  spleen  and  heart,  tenderness  over  the  spleen,  and  great 
shortness  of  breath.     Hemorrhage  is  generally  violent. 

Treatment. — At  once  remove  the  spleen. 

Rupture  of  the  Kidney  (page  770). 

1  The  author,  in  Medical  News,  June  9,  1S94. 


632  MODERN  SURGERY. 

Rupture  of  the  Ureter  (page  772). 

Wounds  of  the  Abdominal  Wall. — Non-penetrating- 
■wounds  are  to  be  treated  on  general  principles.  Suture  with 
great  care  and  apply  external  support.  Ventral  hernia  may 
follow  a  large  wound. 

Penetrating-  "Wounds. — The  symptoms  of  penetrating 
wounds  of  the  abdominal  wall  are  usually  those  of  shock 
and  hemorrhage,  and  later  of  septic  peritonitis.  Emphysema 
is  apt  to  occur.  Viscera  may  protrude.  In  an  incised  or  a 
lacerated  wound  some  of  the  contents  of  the  abdomen  may 
protrude.  If  protruding  viscera  are  uninjured,  they  are 
cleansed  with  hot  sterile  normal  salt  solution  and  returned 
into  the  abdomen,  the  wound  being  enlarged  if  necessary. 
The  belly  is  flushed  out  with  hot  salt  solution  to  remove 
blood-clots,  a  drainage-tube  is  inserted,  the  peritoneum  is 
sutured  with  catgut,  and  the  muscles  and  integument  are  ap- 
proximated with  silkworm-gut.  If  the  viscera  are  injured, 
treat  them  appropriately.  In  punctured  and  in  gunshot- 
wounds,  when  the  intestine  has  been  perforated,  rectal  insuf- 
flation of  hydrogen  will  often  disclose  the  fact,  but  eviscera- 
tion may  be  necessary.  Always  arrest  bleeding.  In  punct- 
ured wounds  enlarge  the  wound  of  entrance,  examine  for 
injury  of  viscera,  close  perforations  if  any  are  found,  flush 
out  the  belly,  drain,  and  close  the  wound.  In  gunshot- 
wounds  the  bullet  may  be  located  by  the  ^-rays.  In  a  case 
of  gunshot-wound  look  if  there  is  a  wound  of  exit,  and  de- 
termine if  the  ball  is  lodged. 

If  the  symptoms  point  to  severe  hemorrhage,  open  the 
belly  at  once  in  the  middle  line,  arrest  the  hemorrhage  (page 
267),  examine  the  viscera,  and  endeavor  to  repair  damage. 
If  the  bullet  is  found,  remove  it. 

If  the  symptoms  do  not  point  to  hemorrhage,  bring  about 
reaction  before  operating.  When  the  patient  is  ready  for  oper- 
ation follow  the  track  of  entrance  by  means  of  a  knife  and 
a  grooved  director ;  open  the  peritoneum  at  the  point  the 
bullet  entered ;  arrest  hemorrhage ;  look  for  perforations 
and  close  them  ;  examine  viscera ;  search  for  the  ball,  but 
do  not  search  long,  and  if  it  is  found,  remove  it ;  flush  out 
the  belly  with  hot  salt  solution  ;  dry  with  gauze  pads  ;  drain  ; 
and  close  the  wound.  In  some  cases  of  penetrating  wounds 
of  the  abdomen  enterectomy  and  end-to-end  approximation 
will  be  required.  All  punctures  or  tears  must  be  sutured  (en- 
terorrhaphy).  Irrigation  of  the  cavity  is  only  required  when 
the  contents  of  the  stomach  or  the  bowel  have  escaped  or  when 
a  considerable  hemorrhage  has  taken  place.     The  surgeon 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       633 

should  drain  when  the  contents  of  the  stomach  or  the  in- 
testines have  escaped,  when  hemorrhage  is  severe,  or  when 
the  liver,  pancreas,  kidney,  or  spleen  is  damaged.  Active 
stimulation  and  artificial  heat  are  needed  immediately  after 
the  operation  to  combat  shock.  In  many  cases  intravenous 
transfusion  of  normal  salt  solution  is  of  great  value.  It  may 
be  given  during  and  after  operation.  Enteroclysis  of  hot 
saline  fluid  is  useful.  The  after-treatment  consists  of  rest, 
opium  in  small  amounts  to  arrest  peristaltic  action,  avoid- 
ance of  food  by  the  stomach  for  forty-eight  hours,  and 
the  administration  of  brandy  and  water  from  time  to  time. 
Feed  by  the  rectum  for  two  days.  On  the  appearance 
of  the  first  sign  of  peritonitis,  forty-eight  hours  or  more 
after  the  operation,  give  a  saline  cathartic.  It  is  not  wise  to 
purge  during  the  first  forty-eight  hours  after  the  operation. 
When  there  is  no  sign  of  peritonitis,  do  not  purge  until  the 
fourth  day.  After  forty-eight  hours  liquid  food  can  usually 
be  given  by  the  stomach.  Solid  food  may  be  given  after 
seven  or  eight  days,  but  the  patient  must  not  leave  his  bed 
until  the  wound  is  solidly  united,  because  of  the  danger  of 
ventral  hernia.     A  support  should  be  worn  for  a  long  time. 

Stomach  and  Intestines. 

Foreigfn  Bodies  in  the  Alimentary  Canal. — These 
accidents  are  rare  except  in  children,  insane  people,  or 
drunkards.  Most  foreign  bodies  swallowed  are  passed  with 
the  feces,  but  some  lodge.  Any  body  which  can  pass  the 
esophagus  is  not  too  large  to  pass  through  the  intestines. 
A  foreign  body  may  lodge  in  the  stomach.  In  some  cases 
there  are  no  symptoms.  In  other  cases  symptoms  are  vio- 
lent. The  severity  of  the  symptoms  depends  upon  the  shape 
and  character  of  the  body. 

In  some  cases  it  is  possible  to  feel  the  body  from  without. 
A  metal  body  in  the  stomach  will  deflect  a  magnetic  needle 
held  over  the  viscus  (Pollailon).  Many  foreign  bodies  can 
be  skiagraphed.  It  is  not  wise  to  attempt  to  recov^er  the 
body  by  inducing  vomiting.  In  some  cases  gastrotomy  is 
necessary.  When  a  foreign  body  has  been  swallowed  the 
usual  treatment  is  as  follows  :  a  purgative  should  ucz'cr  be 
given  to  expedite  the  passage  of  a  foreign  body,  because 
increased  peristalsis  means  increased  danger  of  impaction  or 
of  perforation.  Endeav'or  to  encrust  the  foreign  body,  and 
thus  lessen  the  danger  of  perforation,  by  feeding  with  bread 
and  milk  only  for  several  days,  and  at  the  end  of  this  period 


634  MODERN  SURGERY. 

give  a  mild  laxative.  An  exclusive  diet  of  mush  or  of 
mashed  potatoes  has  been  suggested.  Pain  is  relieved  by 
opium.  A  foreign  body  rarely  lodges  in  the  duodenum,  but 
may  lodge  lower  down,  and  may  cause  ulceration,  perforation, 
abscess,  or  intestinal  obstruction.  Operation  may  be  neces- 
san.'  in  such  cases. 

Cancer  of  the  Stomach.. — Innocent  tumors  and  sarco- 
mata occasionally  attack  the  stomach,  but  they  are  infinitely 
rare  in  comparison  with  primary'  cancer.  This  disease  is  rare 
before  the  age  of  fort}%  and  is  more  common  in  men  than  in 
women.  In  a  ver}'  few  instances  cancer  has  been  found  to 
have  arisen  from  an  ulcer.  The  forms  of  cancer  met  with, 
set  forth  in  their  order  of  frequency,  are,  according  to  Osier,, 
epithelioma,  encephaloid,  scirrhus,  and  colloidal.  Cancer 
may  be  limited  to  the  body  of  the  stomach  (either  cur\'ature 
or  either  wall),  the  pyloric  end,  or  the  cardiac  end,  but  it  may 
involve  two  of  these  regions,  or  almost  the  entire  stomach, 
or,  being  multiple,  may  be  found  in  many  parts.  It  is  fatal 
in  from  four  months  to  two  years. 

Symptoms. — The  disease  comes  on  gradually,  usually 
with  indigestion  and  physical  weakness.  The  patient  has 
persistent  dragging  pain,  which  is  increased  by  eating  and 
pressure,  and  attacks  of  vomiting  are  frequent.  After  a 
short  time  the  patient  becomes  very  weak  and  excessively 
anemic,  and  it  is  often  possible  to  feel  a  tumor  in  the 
stomach.  The  vomiting  of  gastric  cancer  is  at  first  only 
occasional,  but  as  the  case  progresses  becomes  more  and 
more  frequent.  Vomiting  soon  after  eating  occurs  when  the 
cardiac  region  is  involved ;  vomiting  an  hour  or  so  after  eat- 
ing occurs  when  the  pyloric  end  is  involved.  When  the  body 
of  the  organ  is  the  seat  of  disease,  vomiting  may  be  absent. 
The  vomited  matter  is  often  mixed  with  a  small  amount  of 
altered  blood  (coffee-ground  vomit).  In  most  cases  free 
hydrochloric  acid  is  not  found  in  the  stomach,  but  lactic  acid 
is  found.  Examine  with  care  a  patient  in  whom  cancer  is 
suspected. 

Distend  the  stomach  with  gas  or  fluid  and  map  out  its 
outlines.  Feel  for  a  tumor.  A  tumor  can  usually  be  felt  if 
it  involves  the  pylorus,  greater  cur\^ature,  or  anterior  wall, 
but  not  in  other  regions.  Give  a  test-meal,  siphon  off  con- 
tents of  stomach,  and  examine  for  free  hydrochloric  acid 
and  for  lactic  acid.  Ewald's  test-breakfast  is  usually  em- 
ployed. It  consists  of  a  dr}^  roll  and  three-fourths  of  a  pint 
of  weak  tea  or  warm  water.  It  is  given  on  an  empty  stomach. 
After  an  hour  the  stomach-tube  is  introduced.     The  fluid  is 


DISEASES  AiVD   INJURIES   OF  THE  ABDOMEN.       635 

removed  by  a  pump  or  by  abdominal  compression  (May- 
lard). 

Cancer  of  the  cardiac  end  interferes  ^vith  the  entrance  of 
food  into  the  stomach,  and  in  such  a  case  the  stomach  is 
shrunken  and  the  esophagus  is  dilated  immediately  above 
the  growth.  In  cancer  of  the  pylorus  the  food  is  partially 
or  completely  arrested  as  it  passes  to  emerge  from  the 
stomach,  and  the  stomach  becomes  much  dilated.  The 
vomited  matter  in  a  case  of  cancer  rarely  contains  recog- 
nizable fragments  of  the  growth,  but  fluid  with  which  the 
stomach  has  been  irrigated  may  contain  pieces  which  can  be 
identified  as  cancer  (Rosenbach). 

In  cancer  of  the  stomach  the  general  course  of  the  tem- 
perature is  normal,  but  there  are  occasional  deviations  to 
below  or  above  normal.  In  many  cases  the  urine  contains 
albumin,  indican,  acetone,  and  casts.  Cancer  of  the  stomach 
is  apt  to  involve  adjacent  organs  or  structures,  especially 
the  liver.  In  many  cases  exploratory  incision  is  justi- 
fiable. 

Treatment. — The  medical  treatment  consists  in  lavage, 
milk-diet,  and  the  use  of  morphin.  In  order  to  perform  lavage 
introduce  a  soft-rubber  stomach-tube.  Grease  the  tube  with 
glycerin,  hold  the  patient's  tongue  with  the  left  index  finger, 
carry  the  tube  to  the  posterior  wall  of  the  larynx,  and  tell 
the  patient  to  swallow  while  the  tube  is  being  urged  in  by 
the  surgeon.  A  funnel  is  inserted  into  the  raised  tube  and 
fluid  is  poured  in.  After  a  time  the  tube  is  lowered  and  the 
patient  is  asked  to  expel  the  fluid.  This  proceeding  is  re- 
peated till  the  fluid  becomes  clear. 

Surgical  treatment  aims  at  the  removal  of  the  growth,  or 
obviating  the  effect  of  obstruction  at  one  of  the  orifices  of 
the  stomach. 

In  cancer  of  the  body  of  the  stomach,  if  the  growth  is  not 
extensive,  excision  may  be  performed  ;  if  it  is  extensive,  it  is 
useless  to  attempt  it  unless  the  growth  is  absolutely  non- 
adherent, Schlatter  of  Zurich  has  successfully  removed 
the  entire  stomach  and  attached  the  esophagus  to  the  small 
intestine.  In  this  patient  digestion  is  satisfactorily  performed, 
although  the  stomach  is  gone.  Very  rarely  will  cases  be 
found  suitable  for  such  a  radical  proceeding.  In  stricture  of 
the  cardiac  orifice  of  the  stomach  the  surgeon  usually  keeps 
the  passage  open  as  long  as  possible  by  the  frequent  passage 
of  a  tube,  and  through  this  tube  introduces  liquid  food.  Some- 
times a  small  tube  is  introduced  and  permanently  retained.  If 
a  tube  cannot  be  introduced  gastrostomy  is  performed,  and 


636  MODERN  SURGERY. 

through  this  artificial  opening  the  patient  is  fed  (page  678). 
In  cancer  of  the  pylorus  limited  in  extent  and  without  lym- 
phatic involvement, pylorectomy  (page675)  maybe  performed; 
but  in  cancer  which  has  widely  infiltrated  the  coats  of  the 
stomach  and  has  involved  the  lymphatic  glands,  gastro- 
enterostomy is  performed  as  a  palliative  measure,  the  patient 
during  the  rest  of  his  life  subsisting  upon  liquid  or  semi- 
liquid  foods  and  submitting  to  frequent  irrigation  of  the 
stomach  to  remove  food-residue.  In  cases  of  ineradicable 
cancer  it  is  usually  best  to  create  the  opium-habit. 

Peptic  Ulcer  of  the  Stomach. — Ulcer  of  the  stomach 
is  a  condition  due  to  digestion  of  a  portion  of  the  stomach- 
wall  by  very  acid  gastric  juice,  the  destroyed  portion  having 
been  the  seat  of  lowered  vitality. 

Ulcers  are  more  common  in  females  than  in  males,  and  are 
more  frequent  in  young  women  than  in  those  of  middle  or 
advanced  age.  Men  about  forty  and  women  under  forty 
are  liable.  There  is  usually  a  single  ulcer,  but  in  some 
cases  there  are  two  or  more.  The  ulcer  may  heal  or  may 
perforate.  The  most  common  seats  of  ulcer  are  the  pos- 
terior wall  and  lesser  curvature,  especially  in  the  pyloric 
region.  Only  2  per  cent,  of  ulcers  on  the  posterior  wall 
perforate  (Alderson),  as  they  tend  to  form  adhesions  to  adja- 
cent structures.  Ulcers  on  the  anterior  wall  are  unusual,  do 
not  tend  to  form  adhesions,  and  are  apt  to  perforate.  Dis- 
order of  menstruation  may  develop  ulcer,  so  may  tight  lacing, 
and  habitually  bending  over,  as  in  making  shoes.  Chlorosis 
is  associated  with  ulcer  in  many  cases.  Traumatism  and 
swallowing  corrosive  liquid  may  lead  to  ulceration.  Alderson 
believes  that  alcoholism,  syphilis,  and  mental  anxiety  may 
lead  to  the  condition.  Ulcers  due  to  syphilis  and  tubercle 
are  not,  be  it  remembered,  peptic  ulcers. 

Symptoms. — Acid  dyspepsia  exists,  associated  with  much 
flatulence.  In  most  cases,  though  not  in  all,  food  aggra- 
vates the  condition.  In  many  of  these  patients  vomiting 
occurs  about  two  hours  after  eating.  The  vomited  matter 
contains  much  hydrochloric  acid.  Hemorrhage  from  the 
stomach  tends  to  occur.  The  blood  may  be  brought  up 
with  food,  and  is  then  black  and  clotted,  or  may  be  vomited 
clear  and  in  large  amount.  In  some  cases  blood  from  the 
stomach  is  passed  by  the  bowels  in  part  or  wholly.  Paroxys- 
mal pain  exists,  which  is  usually,  but  not  invariably,  aggra- 
vated by  taking  food.  The  pain  is  very  violent  in  the  abdo- 
men, and  also  passes  to  the  back,  being  located  between  the 
eighth  and  ninth  lumbar  vertebrae  (Alderson). 


DISEASES  AND   INJURIES   OF  THE  ABDOMEN.       637 

In  gastric  ulcer  it  is  usual  to  find  tenderness  developed  by 
abdominal  pressure. 

If  the  ulcer  does  not  cicatrize,  but  progresses,  causing  pain 
and  hemorrhage,  the  patient  becomes  thin,  anemic,  weak, 
and  even  exhausted. 

It  is  highly  probable  that  many  cases  of  gastric  ulcer  are 
unrecognized ;  in  fact,  as  Habershon  says,  diagnosis  is  rarely 
made  unless  hemorrhage  exists,  and  in  certain  latent  cases 
both  vomiting  and  bleeding  are  absent. 

A  gastric  ulcer  may  cicatrize  and  thus  become  cured,  but 
the  cure  of  the  ulcer  may  prove  the  ruin  of  the  stomach  by 
producing  stenosis  of  one  of  the  stomach  orifices,  or  hour- 
glass contraction  of  the  body  of  the  stomach.  An  ulcer  may 
perforate,  causing  violent  pain,  shock,  and  acute  peritonitis. 
Perforation  occurs  after  a  meal  or  after  drinking  liquid,  and 
is  brought  about  by  muscular  effort.  Alderson  calls  atten- 
tion to  the  fact  that  the  sudden  perforation  of  an  ulcer  may 
be  mistaken  for  poisoning,  and  he  cites  the  death  of  the 
Duchess  of  Orleans  in   1670.^ 

Treatment. — Medical. — Rest  in  bed.  Rectal  feeding  for  a 
time,  followed  by  the  use  of  a  bland  diet.  Lavage  twice  a 
day.  To  some  cases  Carlsbad  salts  are  given  (Ziemssen), 
to  others  silver  nitrate,  bismuth  subnitrate,  or  oxalate  of 
cerium.     If  pain  is  severe  opium  is  required. 

Surgical. — If  the  patient  grows  worse  in  spite  of  medical 
treatment,  if  the  hemorrhage  has  been  profuse,  if  the  pain  is 
violent,  or  if  tenderness  is  marked,  open  the  abdomen  and 
inspect  the  stomach.  An  ulcer  may  be  removed  by  an  ellipti- 
cal incision  in  the  long  axis  of  the  stomach,  the  coats  being  su- 
tured by  the  usual  method.  If  the  patient  is  bleeding  to  death 
because  of  an  ulcer,  open  the  abdomen  while  an  assistant  is 
giving  an  intravenous  injection  of  salt  solution,  open  the 
stomach,  turn  out  clot,  find  the  source  of  bleeding,  and  ex- 
cise the  ulcer.  In  perforation  bring  about  reaction  from 
shock,  open  the  abdomen,  excise  the  ulcer,  wash  out  the 
stomach,  sew  up  the  perforation,  wash  out  the  abdomen, 
and  close.  Of  late  a  number  of  cases  have  been  success- 
fully operated  upon  (see  Barling,  etc.). 

Cicatricial  stenosis  of  the  orifices  of  the  stomach 
results  from  the  healing  of  an  ulcer,  the  swallowing  of  a  cor- 
rosive substance,  or  a  traumatism  from  a  foreign  body.  Con- 
striction of  the  cardiac  orifice  is  indicated  by  gradually 
increasing  difficulty  in  swallowing.  After  a  time  the  esopha- 
gus above  the  stricture  dilates  or  pouches  ;  the  fluid  food 
1  Provincial  Med.  Jour.,  Dec.  2,  1S95. 


638  MODERN  SURGERY. 

passes  into  the  stomach,  but  the  sohd  food  lodges  in  the 
esophageal  pouch  and  is  soon  regurgitated.  The  site  of  the 
stricture  is  located  by  a  bougie,  and  by  having  the  patient 
swallow  while  ausculting  over  the  esophagus  and  cardiac 
end  of  the  stomach.  If  the  constriction  be  malignant,  the 
patient  will  be  found  to  be  beyond  middle  life,  the  vomit  is 
occasionally  bloody,  emaciation  is  rapid  and  decided,  and 
occasionally  the  supraclavicular  glands  are  enlarged.  A 
tumor  of  the  cardiac  end  of  the  stomach  can  rarely  be 
felt.  If  the  constriction  be  cicatricial,  the  history  will  exhibit 
the  cause.  Constriction  of  the  pyloric  orifice  causes  retention 
of  food  and  dilatation  of  the  stomach.  Dyspeptic  symptoms 
will  be  found  to  have  been  long  present.  A  tube  passed  into 
the  stomach  permits  of  the  injection  of  fluid  so  as  to  fill  the 
stomach.  When  the  fluid  runs  out  it  contains  portions  of 
undigested  food  eaten  days  before,  and  measurement  of  the 
liquid  shows  that  the  capacity  of  the  stomach  is  enormously 
increased.  If  hydrogen  be  forced  through  the  tube,  the 
outline  of  the  distended  stomach  is  at  once  made  clear. 
The  usual  method  of  distending  the  stomach  is  by  a 
Seidlitz  powder  :  two  solutions  are  made ;  the  bicarbonate 
solution  is  swallowed  at  once,  and  the  tartaric  solution  is 
taken  afterward  in  small  amounts  at  a  time.  Percussion 
over  the  distended  stomach  indicates  the  size  of  the 
viscus. 

In  malignant  disease  of  the  pylorus  a  tumor  may  often  be 
made  out ;  there  are  tenderness  and  considerable  persistent 
pain,  great  emaciation  and  sometimes  enlargement  of  the 
supraclavicular  glands.  Vomiting  of  bloody  fluid  occurs. 
In  cicatricial  stenosis  of  the  pylorus  there  may  be  paroxysms 
of  pain,  there  is  no  tenderness,  emaciation  is  not  so  rapid  in 
onset,  and  the  supraclavicular  glands  are  never  enlarged. 
Vomiting  occurs,  but  the  ejected  matter  is  not  bloody. 
Illumination  of  the  stomach  by  the  gastrodiaphanoscope 
may  aid  the  diagnosis,  the  area  of  malignant  growth  inter- 
fering with  the  transmission  of  light. 

Treatment. — Cardiac  stenosis  requires  dilatation  with 
bougies  and  the  maintenance  of  the  restored  caliber.  If 
this  dilatation  from  above  is  unsatisfactory,  perform  a  gas- 
trotomy,  push  a  small  bougie  from  the  mouth  into  the 
stomach,  tie  a  string  to  the  bougie,  draw  the  string  through 
the  stricture,  use  the  string  as  a  saw  to  cut  the  fibrous 
bands,  pass  a  full-sized  bougie,  close  the  wound  in  the 
stomach,  and  maintain  the  caliber  by  the  repeated  passage 
of  dilating  instruments.     If  no  instrument  can  be  passed 


DISEASES  AND  INJURIES  OF   THE  ABDOMEN.       639 

through  the  stricture  from  above,  perform  a  gastrotomy, 
introduce  an  instrument  from  below,  and  use  Abbe's  string 
saw.  If  no  instrument  can  be  passed  from  below,  convert 
the  gastrotomy  into  a  gastrostom)-.  Pyloric  stenosis  is 
treated  by  a  gastrotomy  and  digital  divulsion  of  the  strict- 
ure (Loreta's  operation),  by  pyloroplasty  (Heineke-Mikulicz 
operation),  by  gastro-enterostomy,  or  by  pylorectomy. 

Intestinal  Obstruction  (Ileus  or  Enterostenosis). — 
Intestinal  obstruction  is  a  condition  in  which  fecal  move- 
ment is  mechanically  impeded  or  prevented.  It  may  be 
either  partial  or  complete.  Acute  obstniction  is  due  to  a 
sudden  narrowing  or  occlusion  of  the  lumen  of  a  portion 
of  the  intestine.  Chronic  obstructioji  is  due  to  a  gradual 
narrowing  of  the  lumen  of  a  portion  of  the  intestine,  and  it 
may  at  any  time  become  acute.  If  obstruction  to  circulation 
in  the  wall  of  the  bowel  occurs,  the  condition  becomes  one 
of  strangulation.  Intestinal  obstructions  are  classified  ^  as 
follows : 

1.  Strangulation  by  bands  or  in  apertures,  the  commonest 
form,  is  due  to  peritoneal  adhesions,  but  the  band  may  come 
from  the  omentum.  Strangulation  may  take  place  by 
Meckel's  diverticulum,  a  structure  due  to  persistence  of  the 
vitelline  duct,  and  coming  off  from  the  ileum  from  twelve  to 
thirty-six  inches  above  the  ileocecal  valve.  Strangulation 
may  take  place  beneath  an  adherent  appendix,  a  Fallopian 
tube,  a  portion  of  mesenter}^  or  the  pedicle  of  an  ovarian 
tumor,  or  it  may  take  place  in  an  omental  or  a  mesenteric 
aperture.  Strangulation  by  bands  or  in  apertures  usually 
involves  the  ileum,  and  sometimes  the  colon.  This  form  of 
obstruction  is  identical  with  hernia,  excepting  in  the  absence 
of  an  external  protrusion. 

2.  Volvulus,  or  twisting  of  the  bowel.  The  twist  may  be 
about  the  mesenteric  axis  or  on  the  axis  of  the  bowel  itself, 
or  two  intestinal  coils  may  be  twisted  together.  Volvulus  is 
commonest  in  the  sigmoid  flexure. 

3.  Intussusception  is  the  invagination  of  a  portion  of  bo\\'el- 
wall  into  the  lumen  of  an  adjacent  part.  One-third  of  all 
cases  of  obstruction  are  due  to  this  cause  (Treves).  Most 
cases  of  obstruction  in  children  are  due  to  intussusception. 
There  are  four  varieties  :  the  ileocecal,  in  which  the  ileum 
and  the  ileocecal  valve  pass  into  the  cecum  and  colon ;  the 
colic,  in  which  the  large  intestine  is  prolapsed  into  itself;  the 
ileal,  in  which  the  small  intestine  alone  is  involved ;  and  the 
ileocolic,  in  which  the  ileum  prolapses  through  the  ileocecal 

^  After  Treves,  in  Heath's  Dictionary. 


640  MODERN  SURGERY. 

valve.     The  first  variety  is  the  commonest.     Intussusception 
is  due  to  active  peristalsis. 

4.  Stricture  of  the  intestine,  which  may  be  either  cicatricial 
or  cancerous. 

5.  Obstruction  by  Tumors  of  the  Bowel  arid  by  Foreign 
Bodies. — Tumors  may  be  innocent  or  malignant.  Foreign 
bodies  include  besides  certain  substances  that  have  been 
swallowed,  gall-stones,  and  enteroliths  or  intestinal  calculi. 
Foreign  bodies  are  apt  to  lodge  in  the  lower  portion  of  the 
ileum  or  in  the  cecum,  and  they  may  cause  ulceration  at 
the  seat  of  lodgement.  If  a  gall-stone  is  sufficiently  large 
to  cause  obstruction,  it  cannot  have  passed  the  duct,  but 
must  have  ulcerated  into  the  bowel  from  the  gall-bladder 
(Treves). 

6.  Obstruction  by  tumors,  etc.  outside  the  bowel,  among  the 
causes  of  which  are  retroflexion  or  retroversion  of  the  womb, 
especially  in  pregnancy,  cysts  or  tumors  of  the  kidneys, 
ovaries,  uterus,  etc.,  floating  kidney,  and  enlarged  spleen. 
Obstruction  from  any  of  the  above  causes  takes  place  in 
the  rectum  or  the  sigmoid  flexure. 

7.  Obstruction  from  fecal  accumulation  is  due  to  paresis 
or  paralysis  of  the  bowel  and  the  diminution  or  abolition  of 
peristalsis.  Obstruction  may  follow  an  abdominal  opera- 
tion. Paresis  or  paralysis  arises  in  the  colon.  Treves 
mentions  among  the  rare  forms  of  obstruction  kinking  of 
the  bowel,  adhesions  matting  the  bowels  together  or  com- 
pressing the  gut,  and  shrinking  of  the  mesentery. 

Symptoms  of  Acute  Obstruction. — Severe  colic  comes 
on  suddenly,  the  pain  varying  in  intensity,  but  at  no  time 
entirely  ceasing ;  there  is  constipation  which  soon  becomes 
absolute,  not  even  wind  being  passed ;  vomiting  is  early — 
first  of  the  contents  of  the  stomach,  next  of  bilious  matter, 
and  finally  of  feces  (stercoraceous) ;  the  abdomen  becomes 
distended  and  tender ;  some  fever  may  be  found  at  the  start, 
but  collapse  soon  arises  ;  the  temperature  becomes  subnor- 
mal ;  the  face  Hippocratic  ;  the  pulse  rapid  and  feeble.  The 
amount  of  urine  passed  is  very  small.  In  obstruction  of  the 
upper  third  of  the  ileum  true  fecal  vomiting  cannot  occur. 
The  tongue  is  dry,  the  mind  is  clear,  and  muscular  cramp 
may  occur.  Intestinal  peristalsis  above  the  obstruction  may 
be  detected  through  the  abdominal  wall.  If  obstruction  is 
high  up  in  the  small  intestine,  tympanites  does  not  occur. 

Symptoms  of  Chronic  Obstruction. — At  intervals  there 
arise  attacks  of  pain  which  become  gradually  more  frequent 
and  severe  and  are  linked  with  vomiting  and  constipation. 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       64 1 

the  vomiting  not  being  stercoraceous  and  the  constipation 
not  being  absolute.  Between  the  painful  seizures  the  patient 
complains  of  constipation  alternating  with  fluid  diarrhea, 
distention  of  the  belly,  some  abdominal  uneasiness,  ano- 
rexia, and  dyspepsia.  The  attacks  recur  with  increasing 
frequency  and  severity,  and  acute  obstruction  may  arise  or 
the  patient  may  be  worn  out  by  pain,  vomiting,  and  want 
of  food. 

Diagnosis. —  The  determination  of  the  seat  of  lesion  re- 
quires rectal  examination.  An  intussusception  may  some- 
times be  felt.  Vaginal  examination  may  be  demanded.  Pain 
is  apt  to  arise  at  the  seat  of  obstruction  or  to  radiate  from 
there.  Palpation  may  detect  a  tumor.  Rectal  insufflation 
of  hydrogen  may  locate  the  obstruction  by  causing  great 
distention  below  it.  Entire  suppression  of  urine,  early  vomit- 
ing which  is  not  truly  stercoraceous,  absence  of  abdominal 
distention,  and  rapid  collapse,  mean  obstruction  in  the  duo- 
denum or  in  the  jejunum.  Early  vomiting,  which  is  often 
stercoraceous  in  a  rapidly  progressive  case  with  great  dis- 
tention of  the  umbilical  region,  means  obstruction  of  the 
ileum  or  the  cecum  (Pepper).  Distention  of  the  entire 
abdomen  and  of  the  flanks,  linked  with  tenesmus,  with 
less  intensity  of  symptoms,  less  rapidity  of  progress,  and 
less  diminution  of  urine  than  in  the  above-cited  forms, 
means  obstruction  low  down  in  the  colon  or  in  the  rectum 
(Pepper).  A  test  for  obstruction  in  the  adult  large  intes- 
tine is  an  injection  by  a  fountain  syringe :  if  six  quarts  can 
be  introduced,  there  is  no  obstruction  in  the  large  intestine ; 
if  less  than  four  quarts  can  be  introduced,  there  is  probably 
obstruction  in  the  large  intestine.  The  passage  of  a  sound 
in  the  rectum  is  generally  useless  and  is  often  unsafe. 

TJic  determination  of  the  causative  condition  is  always  diffi- 
cult and  is  often  impossible.  Intussusception  is  the  common 
cause  in  children.  A  sausage-shaped  tumor  can  usually  be 
felt  in  the  right  iliac  fossa,  tenesmus  exists,  and  bloody  mucus 
is  passed.  The  abdomen  is  rarely  distended  or  tender.  Vom- 
iting occurs,  but  it  is  seldom  stercoraceous.  The  prolapse 
may  sometimes  be  detected  by  digital  exploration  of  the  rec- 
tum. In  obstruction  from  bands,  internal  hernia,  etc.  there 
is  a  record  of  antecedent  peritonitis,  of  a  traumatism,  of  a  vio- 
lent effort,  or  of  pelvic  pain.  The  attack  is  sudden  in  onset, 
is  fierce  in  character,  and  is  usually  excited  by  violent  exer- 
cise or  the  taking  of  food.  Vomiting  is  early  and  intractable, 
and  it  soon  becomes  stercoraceous  ;  pain  is  violent ;  peristal- 
sis above   the    obstruction  is  forcible;    tympanites  and  ab- 

41 


642  MODERN  SURGERY. 

dominal  tenderness  appear  after  the  attack  has  lasted  for 
some  httle  time;  obstruction  is  complete,  no  wind  even 
being  passed ;  collapse  soon  appears ;  no  tumor  can  be 
detected,  and  rectal  examination  is  negative.  Volvulus,  which 
is  usually  located  in  the  sigmoid  flexure,  is  preceded  by  con- 
stipation. The  symptoms  come  on  with  explosive  sudden- 
ness, and  rapidly  attain  great  severity.  Constipation  is  abso- 
lute ;  vomiting  is  late  and  is  rarely  stercoraceous ;  no  tumor 
can  be  detected ;  rectal  examination  is  negative ;  abdominal 
distention  and  tenderness  are  early  and  pronounced ;  peris- 
talsis above  the  volvulus  is  vigorous ;  collapse  is  not  so 
rapid  nor  so  grave  as  in  the  previously-considered  forms. 
Obstruction  by  a  foreign  body  may  sometimes  be  inferred 
by  the  history  of  some  such  body  having  been  swallowed. 
The  obstructing  body  may  occasionally  be  felt  during  palpa- 
tion, or  may  be  discovered  with  the  X-rays.  Abdominal 
distress  may  exist  for  days  or  weeks  before  obstruction 
occurs.  Vomiting  is  late  and  is  rarely  severe,  but  pain, 
tenderness,  and  distention  are  marked.  In  obstruction  from 
gall-stones  there  will  be  a  record  of  one  or  more  attacks  of 
hepatic  colic.  Pain  is  early  and  acute,  and  vomiting  is  invari- 
able and  usually  becomes  stercoraceous.  In  obstruction  from 
fecal  accumulation  chronic  obstruction  evolves  into  acute 
obstruction,  pain  and  vomiting  are  late  or  even  absent,  and 
the  dough-like  mass  of  feces  may  often  be  felt  by  rectal  ex- 
amination or  by  abdominal  palpation.  In  some  cases  the 
fluid  elements  of  the  feces  pass,  but  the  soHd  elements  agglu- 
tinate to  the  walls  of  the  bowel  (the  diarrhea  of  constipation). 
Obstruction  from  stricture  or  from  pressure  comes  on  acutely 
after  a  prolonged  period  of  disturbance,  during  which  period 
attack  after  attack  of  temporary  obstruction,  complete  or 
partial,  takes  place.  A  history  of  blood  or  pus  in  the  stools 
would  indicate  tumor  of  the  bowel ;  a  history  of  blood  or 
pus  having  been  absent  would  indicate  pressure  from  without 
(Pepper).  In  functional  obstruction  there  is  no  local  pain, 
no  tenderness,  no  tumor,  no  tendency  to  collapse,  but  simply 
distention  and  absolute  constipation,  and  possibly  non-fecal 
vomiting  occurring  in  a  neurotic  or  hysterical  subject.  A 
phantom  tumor  due  to  a  local  distention  of  the  intestine  from 
limited  muscular  spasm  disappears  under  ether.  Obstruc- 
tion may  follow  an  abdominal  operation  (post-operative  ob- 
struction) ;  it  may  arise  a  day  or  so  after  operation ;  it  may 
arise  in  ten  or  twelve  days  after  operation ;  it  may  not  arise 
for  weeks  or  months  (Legeve).  It  may  be  due  to  some 
cause  at  the  seat  of  operation  (adhesion  of  the  bowel  to  a 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       643 

raw  surface,  volvulus,  catching  under  adhesions,  etc.).  It 
may  be  due  to  some  cause  distant  from  the  seat  of  operation 
(displacement  of  intestine,  bands,  etc.).  It  may  arise  from 
paralysis  of  a  portion  of  the  bowel,  which  may  or  may  not 
be  due  to  sepsis.^ 

Separation  of  Intestinal  Obstructioji  from  Other  Diseases. — 
Always  examine  for  a  strangulated  hernia  at  every  hernial 
outlet.  If  obstruction  is  complicated  with  an  irreducible 
hernia  above  the  seat  of  lesion,  the  hernia  will  always  en- 
large and  become  tender  because  of  accumulation  of  feces 
(Pepper).  Functional  obstruction  may  attend  peritonitis  or 
may  follow  the  reduction  of  a  hernia.  Appendicitis  with 
peritonitis  may  cause  symptoms  similar  to  those  of  obstruc- 
tion, but  there  are  fever,  a  history  of  trouble  in  the  right  iliac 
fossa,  and  the  vomiting  is  not  stercoraceous.  Acute  hemor- 
rhagic pancreatitis  produces  symptoms  so  nearly  identical  with 
those  of  intestinal  obstruction  that  a  diagnosis  cannot  always 
be  made.  Poisoning  by  arsenic  or  by  corrosive  sublimate 
should  not  be  confounded  with  intestinal  obstruction. 

Prognosis. — Without  surgical  interference  most  cases  of 
acute  intestinal  obstruction  die  within  ten  days,  usually  within 
seven  days.  Death  may  be  due  to  shock,  to  exhaustion,  to 
perforation,  to  peritonitis,  or  to  obstruction  of  respiration  and 
circulation  by  tympanites.  Recovery  occasionally  happens 
by  the  formation  of  a  fistula  externally  or  into  another  por- 
tion of  the  bowel.  In  acute  obstruction  from  foreign  bodies 
the  obstructing  body  occasionally  passes.  Volvulus  and 
strangulation  by  bands  are  almost  invariably  fatal  unless  an 
operation  is  performed.  In  intussusception  recovery  occa- 
sionally follows  the  sloughing  away  of  the  prolapsed  gut,  but 
stricture  almost  inevitably  follows  this  rare  event.  Func- 
tional obstruction  gives  a  good  prognosis.  The  prognosis 
of  chronic  obstruction  depends  upon  the  causative  lesion, 
and  is  not  nearly  so  grave  as  is  that  of  acute  obstruction. 

Treatment. — In  any  abdominal  case,  where  the  diagnosis  is 
uncertain  and  the  patient  is  shocked,  give  an  enema  of  brandy 
and  hot  water,  wrap  the  patient  in  blankets,  surround  him 
with  hot-water  bottles,  and  study  the  development  of  symp- 
toms and  signs.  In  half  an  hour,  as  a  rule,  reaction  will  be 
brought  about,  and  a  probable  diagnosis  may  be  made  (Greig 
Smith).  In  acute  obstruction  it  is  usually  customar}^  to 
empty  the  stomach  by  lavage  and  to  evacuate  the  rectum 
by  means  of  copious  injections  given  while  the  patient  is  in 
the  knee-chest  position.     Hutchinson's  method  of  taxis  and 

1  Legeve,  Gaz.  des  Hop.,  Nov.  23,  1895. 


644  MODERN  SURGERY. 

massage  is  uncertain,  and  is  more  liable  to  inflict  harm  than 
to  confer  benefit.  Some  surgeons  apply  constant  compres- 
sion to  the  abdomen  by  means  of  straps  of  adhesive  plaster. 
Puncture  of  the  intestine  with  an  aseptic  hypodermatic  needle 
introduced  obliquely  to  relieve  gaseous  distention  is  a  de- 
cidedly dangerous  proceeding.  The  passage  of  a  small  tube 
from  the  anus  to  the  sigmoid  flexure  will  empty  the  colon  of 
gas  if  no  obstruction  intervene.  In  intussusception  give 
no  food  by  the  stomach;  give  opium  and  belladonna  to  stop 
peristalsis,  wash  out  the  rectum  with  copious  injections,  give 
an  anesthetic,  and  insufflate  hydrogen  gas  or  carbonic  acid  gas 
in  order  to  distend  the  bowel.  Some  surgeons  treat  intussus- 
ception by  forcing  air  into  the  rectum  by  means  of  an  ordinary 
bellows,  and  others  inject  water  by  a  fountain  syringe,  the 
reservoir  standing  at  a  height  of  three  feet.  D'Arcy  Power 
believes  in  the  value  of  hydrostatic  pressure  in  intussuscep- 
tion in  children.  He  states  that  the  child  should  be  anesthet- 
ized and  the  large  intestine  filled  gradually  with  hot  saline 
fluid,  the  reservoir  not  being  raised  more  than  three  feet 
above  the  patient.  The  fluid  should  be  retained  for  ten 
minutes.  The  author  is  of  the  opinion  that  injections  of  gas 
or  liquid  should  be  tried  during  the  first  twenty-four  hours 
of  the  attack,  but  not  later,  because  later  ulcer  or  gangrene 
may  exist.  Pressure  cannot  be  closely  regulated,  and  if  the 
bowel  is  much  damaged  may  lead  to  rupture.  If  the  case  is 
not  seen  until  after  the  first  day,  or  if  injections  have  been 
used  and  have  failed,  laparotomy  should  be  performed. 

Frederick  Holme  Wiggin  has  made  a  study  of  the  reported 
cases  of  laparotomy  for  infantile  intussusception,  and  con- 
siders that  operation  done  within  the  first  forty-eight  hours 
will  give  a  mortality  of  22.2  per  cent.^  (see  Operation  for  In- 
tussusception, page  694). 

In  obstruction  from  fecal  impaction  use  large  rectal  injec- 
tions and  give  small  repeated  doses  of  salines  or  a  mixture  of 
castor  oil  and  oil  of  turpentine.  If  there  are  signs  of  inflamma- 
tion, do  not  give  cathartics,  even  in  small  doses,  but  give  opium 
and  belladonna  to  arrest  vomiting  and  to  relax  spasm.  Im- 
pactions in  the  rectum  can  be  spooned  away.  In  acute  intesti- 
nal obstruction,  if  the  symptoms  grow  worse,  do  not  wait, 
but  open  the  abdomen  before  collapse  comes  on  and  find 
the  cause  of  the  obstruction.  If  it  is  a  gall-stone  or  entero- 
lith, try  to  crush  it  without  opening  the  intestine ;  if  this  fails, 
push  it  up  a  little  distance,  incise  the  bowel,  remove  the  stone, 
and  close  the  incision  with  Halsted  sutures.    If  there  is  fecal 

1  Med.  Record,  Jan.  i8,  1896. 


DISEASES  AND  INJURIES   OF  THE  ABDOMEN.       645 


obstruction,  break  up  the  masses  by  pressure  and  push  the 
fecal  plug  down  without  opening  the  bowel.  If  there  is 
intussusception,  reduce  the  prolapse  and  shorten  the  mesen- 
tery ;  but  if  reduction  is  impossible,  perform  an  anastomosis, 
or  a  resection  and  enterorrhaphy,  or  make  an  artificial  anus. 
In  volvulus  untwist  and  shorten  the  mesentery ;  but  if  this  is 
impossible,  treat  as  an  irreducible  invagination.  In  obstruc- 
tion from  adhesions  try  to  separate  them  and  straighten  out 
the  bowel,  stitching  healthy  peritoneum  over  each  raw  spot 
to  prevent  recurrence.  Anastomosis  may  be  necessary.  In 
flexion  separate  the  intestines,  remove  the  flexion  by  a 
V-shaped  incision,  and  suture  the  wound  in  the  bowel  (Senn). 
In  chronic  obstruction  it  is  often  advisable  to  perform  an  ex- 
ploratory laparotomy  and  determine  by  the  condition  what 
is  to  be  done.  Some  tumors  external  to  the  bowel  are  re- 
moved. Growths  in  the  bowel-wall  may  be  removed  by  resec- 
tion of  the  involved  portion  of  intestine.  Anastomosis  may  be 
performed,  or  an  artificial  anus  may  be  necessary.  Post-oper- 
ative obstruction  coming  on  soon  after  a  surgical  operation 
is  often  not  recognized  for  a  time,  and  the  surgeon  will  be  in 
doubt  as  to  whether  he  is  dealing  with  peritonitis  or  intesti- 
nal paresis.  When  in  doubt  wash  out  the  stomach  with 
warm  salt  solution,  administer  salines  in  small  doses  fre- 
quently repeated,  and  employ  enemata.  If  these  measures 
are  not  soon  successful,  open  the  abdomen ;  never  wait  for 
the  advent  of  stercoraceous  vomiting  (see  Legeve). 

Fecal  Fistula. — A  fistula  is  an  abnormal  opening  in  the 
intestine  through  which  gas  or  a  portion  of  the  feces  escapes 
(Fig.  199).     If  all  the  intestinal  contents  escape  through  the 


Fig.  199 — Fecal  fistula  :  a,  direction 
of  fecal  flow  ;  b,  b,  belly-wall. 


Fig.  200. — Artificial  anus,  showing  spur: 
«,  spur  ;  b,  b,  belly-wall  ;  c,  direction  of  fecal 
flow. 


opening,  it  is  called  an  artificial  anus  (Fig.  200)  (Senn).  A 
surgeon  may  make  a  fistula  deliberately  (intentional  fistula). 
A  fistula  may  be  the  product  of  disease  or  injury  (accidental 
fistula).  Senn  gives  the  following  as  the  causes  of  accidental 
fistula:  wounds,  injury  of  the  intestine,  intestinal  ulceration, 
intestinal  strangulation,  foreign  bodies  in  the  intestinal  canal, 
malignant  tumors,  actinomycosis,  pelvic  and  abdominal  ab- 
scess, appendicitis,  injury  of  the  bowel  during  an  abdominal 


646  MODERN  SURGERY. 

operation,  the  application  of  ligatures,  catching  by  sutures, 
and  the  employment  of  drainage-tubes. 

Treatment. — Many  fistulae  close  spontaneously.  This  can 
only  be  hoped  for  if  the  opening  is  quite  small,  if  the  general 
health  of  the  patient  is  good,  when  the  cause  has  passed  away, 
when  the  fistula  is  not  lined  with  mucous  membrane,  and 
when  there  is  no  spur  (Figs.  199,  200).  In  most  cases  of 
fistula  not  high  up  it  is  well  to  give  nature  a  chance.  The 
part  is  cleansed  frequently  with  peroxid  of  hydrogen,  the  pa- 
tient is  kept  recumbent,  food  is  given  which  does  not  leave 
much  residue,  pads  of  gauze  with  pressure  are  applied,  and 
the  bowels  are  kept  regular. 

If  the  track  is  lined  with  granulations,  it  may  be  touched 
with  lunar  caustic;  if  it  is  lined  with  mucous  membrane,  with 
the  actual  cautery;  any  collection  of  pus  which  exists  should 
be  drained.  If  these  methods  fail,  an  operation  must  be 
performed.  The  fistula  may  be  sutured  by  extraperitoneal 
manipulation  (Greig  Smith) ;  it  may  be  covered  with  skin 
(Dieffenbach) ;  the  spur  may  be  removed  by  means  of  a  clamp; 
or  resection  may  be  performed.  In  some  cases  exclusion 
of  the  fistulous  part  is  necessary,  the  bowel  being  divided 
above  the  fistula,  the  end  near  the  fistula  sutured,  and  the 
other  end  anastomosed  to  the  bowel  below  the  fistula. 

Ulcer  of  the  Bowel. — In  typhoid  fever  and  in  dysentery 
ulceration  occurs.  An  ulcer  may  be  due  to  tuberculosis  or 
cancer.  Ulcer  in  the  duodenum  sometimes  follows  a  severe 
burn  of  the  surface  (Curling's  ulcer).  An  ulcer  may  heal,  and 
by  causing  thickening  and  constriction  produce  intestinal  ob- 
struction. It  may  perforate,  causing  collapse  and  subsequent 
peritonitis.  In  perforation  the  liver-dulness  is  greatly  dimin- 
ished or  disappears  because  of  free  gas  in  the  peritoneal 
cavity.  Perforation  of  a  typhoid  ulcer  is  accompanied  by 
marked  leukocytosis ;  there  is  great  shock,  which  is  usually 
followed  by  a  temporary  reaction,  severe  pain  as  a  rule, 
tenderness,  costal  respiration,  abdominal  distention,  vomit- 
ing which  may  become  eventually  stercoraceous,  constipa^ 
tion,  percussion-dulness  of  the  flank,  and  Hippocratic  face. 

Treatment. — The  intestinal  obstruction  due  to  the  healing 
of  an  ulcer  is  treated  by  intestinal  anastomosis  or  resection. 
If  an  ulcer  perforates,  the  surgeon  aims  to  bring  about  re- 
action. If  this  attempt  succeeds,  the  abdomen  is  opened  and 
is  flushed  out  with  hot  saline  fluid,  special  care  being  taken  to 
flush  away  infected  material  from  the  pelvis  and  from  between 
the  liver  and  diaphragm.  The  perforation  is  to  be  found  and 
sutured.     It  is  not  necessary  to  excise  it.     A  suprapubic  in- 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.      647 

cision  in  addition  to  the  first  incision  renders  drainage  better, 
and  in  some  cases  posterior  drainage  is  inserted  through  the 
right  kidney  pouch.  A  drainage-tube  is  placed  in  each  in~ 
cision,  and  a  tube  is  inserted  in  the  suprapubic  incision  and 
is  carried  into  Douglas's  pouch,  and  the  upper  incision  is  left 
open,  strands  of  iodoform  gauze  being  placed  over  the  area 
of  rupture  and  in  several  places  among  the  intestines.  In 
perforation  Finney  always  eviscerates,  closes  the  perforation, 
wipes  out  the  peritoneal  cavity  with  gauze  pads,  and  returns 
the  bowels  slowly  into  the  abdomen,  wiping  them  carefully. 

Malignant  Tumor  of  the  Intestine. — Sarcoma  is  very 
rare,  but  does  arise  sometimes  in  young  persons  and  enlarges 
very  rapidly.  Cancer  is  not  uncommon,  attacking  especially 
the  middle  aged.  It  is  particularly  common  in  the  neighbor- 
hood of  the  ileocecal  valve  and  in  the  sigmoid  flexure.  It 
produces  pain  at  the  seat  of  growth,  and  after  a  time  intestinal 
obstruction.  It  is  usually  possible  to  feel  the  tumor,  which 
is  hard  and  immovable.  The  patient  wastes  rapidly  and  is 
apt  to  occasionally  pass  blood  at  stool.  The  growth  is  not 
very  rapid  and  glands  are  not  involved  early.  In  some  cases 
the  supraclavicular  glands  enlarge. 

Treatment. — Early  in  the  case  exploratory  laparotomy 
should  be  performed,  followed  if  possible  by  excision  with 
end-to-end  approximation.  If  excision  is  impossible,  the 
growth  should  be  sidetracked  by  performing  lateral  anasto- 
mosis. In  advanced  cancer  of  the  large  bowel  make  an 
artificial  anus  above  the  tumor. 

Appendicitis. — Appendicitis,  which  is  an  inflammation 
of  the  vermiform  appendix  of  the  cecum,  is  almost  invariably 
the  primar}^  lesion  of  all  of  those  various  conditions  known 
as  typhlitis,  perityphlitis,  paratyphlitis,  etc. — terms  which  no 
longer  imply  pathological  entities,  and  are  in  most  instances 
well  relegated  to  obscurity.  The  appendix  is  a  diverticulum 
(musculomembranous  in  structure)  which  comes  from  the 
posterior  and  internal  part  of  the  head  of  the  colon,  and 
which  has  no  physiological  function  (in  herbivora  and  rodents 
it  is  a  functionally  active  organ).  The  structure  of  the  appen- 
dix is  identical  with  the  structure  of  the  colon,  except  that 
the  muscular  structure  is  ill  developed  and  trivial  in  amount. 
The  appendix  averages  about  four  and  a  half  inches  in  length, 
and  its  diameter  is,  as  a  rule,  about  equal  to  that  of  a  No.  9 
English  bougie ;  its  canal  is  narrow  and  is  partly  closed  by 
the  valve  of  Gerlach  (Talamon).  The  appendix  enters  the 
cecum  at  its  posterior  internal  part,  which  is  usually  the  seat 
of  the  most  intense  pain  in  inflammation,  and  corresponds  to 


648  MODERN  SURGERY. 

a  point  on  the  surface  two  inches  from  the  spine  of  the  ilium, 
on  a  hne  drawn  from  the  umbilicus  to  the  anterior  superior 
iliac  spine,  which  is  known  as  "  McBurney's  point."  The 
free  part  of  the  appendix  in  one-third  of  all  persons  is  in 
relation  with  the  posterior  surface  of  the  cecum ;  in  almost 
one-third  of  all  persons  it  is  fixed  in  the  iliac  fossa,  so  that  if 
perforation  occurs  the  contents  will  be  voided  in  the  retroper- 
itoneal tissue  (ihac  abscess).  In  some  cases  it  is  external  to 
the  cecum ;  in  some  it  passes  downward,  and  in  some  inward. 
In  about  two-thirds  of  all  cases  the  appendix  is  completely 
covered  with  peritoneum ;  in  one-third  of  all  cases  it  is  in 
contact,  in  some  part  of  its  length,  with  cellular  tissue 
(Talamon).  Robinson  has  called  attention  to  the  fact  that 
the  appendix  is  frequently  in  contact  with  the  psoas  muscle 
in  men. 

Etiology  and  Pathology. — Appendicitis  is  very  rare  in  in- 
fants, but  is  common  at  any  period  beyond  childhood,  being 
more  frequent  in  young  and  middle-aged  people  than  in  the 
aged.  Appendicitis  is  a  bacterial  disease.  It  is  produced 
occasionally  by  pus  cocci,  but  most  commonly  by  the  action 
of  the  bacterium  coli  commune  of  Escherich.  These  microbes, 
which  normally  inhabit  the  appendix,  are  harmless  when  the 
appendix  is  healthy,  but  become  active  for  harm  when  the 
diverticulum  is  bruised,  obstructed,  or  in  a  state  of  catarrhal 
inflammation.  When  non-traumatic  inflammation  occurs 
swelling  of  the  mucous  membrane  occludes  the  opening 
into  the  colon,  and  the  lumen  of  the  appendix  dilates  and 
fills  up  with  a  thick  or  mucopurulent  fluid.  Ulcers  some- 
times form,  which  may  only  involve  the  mucous  membrane, 
may  pass  deeply  into  the  coats,  or  may  even  perforate.  Dieu- 
lafoy  ^  maintains  forcefully  that  appendicitis  is  due  always  to 
the  conversion  of  the  appendix  into  a  closed  cavity.  Various 
conditions  may  bring  about  this  transformation.  Partial  ob- 
struction may  be  caused  by  calculi,  which  are  composed  of 
stercoral  material  mixed  with  salts  of  Hme  and  magnesia. 
These  calculi  are  not  formed  in  the  colon,  but  are  formed  in 
the  appendix.  Dieulafoy  speaks  of  the  condition  as  appen- 
dicular lithiasis,  and  says  the  condition  has  a  tendency  to  run 
in  family  lines,  and  has  a  kinship  with  gout  and  rheumatism. 
Obstruction  may  be  caused  by  local  infection  of  a  catarrhal 
area,  by  the  formation  of  a  fibrous  stricture,  or  by  several 
causes  acting  in  unison.  The  theory  that  concretions  form 
in  the  colon,  and  are  forced  into  the  appendix  by  peristalsis, 
has  been  very  largely  abandoned.  Talamon  taught  that  the 
1  Progrh  Medicale,  No.  11,  1896. 


DISEASES  AND   INJURIES   OF   THE   ABDOMEN.       649 

appendix  resents  the  presence  of  the  concretion,  reflex  contrac- 
tion of  the  muscular  coat  taking  place,  which  is  accompanied 
by  violent  pain  (appendicular  colic).  The  muscular  structure 
is  so  rudimentary  that  it  does  not  seem  probable  that  at- 
tempts at  contraction,  even  should  they  arise,  would  produce 
violent  pain  and  distant  symptoms.  Pozzi  believes  that  ap- 
pendicular colic  may  be  caused  by  torsion,  or  bending  of  the 
appendix,  or  malposition  of  the  diverticulum,  and  holds  that 
pain  may  arise  when  there  is  no  lesion  in  the  appendix  and 
no  inflammation  of  the  peritoneum  or  pericecal  structures.^ 
Foreign  bodies,  such  as  pins,  fish-bones,  nails,  buttons,  date- 
stones,  cherry-stones,  and  grape-seeds,  may  enter  the  appen- 
dix, but  they  do  so  far  less  often  than  is  generally  supposed, 
most  alleged  grape-seeds  from  the  appendix  being  only  fecal 
concretions.  Fitz  found  concretions  is  1 5  cases  out  of  300. 
Ranvier  collected  the  records  of  459  post-mortems,  and  found 
reported  179  fecal  concretions  and  16  foreign  bodies.  Ap- 
pendicitis due  to  a  foreign  body,  such  as  a  grape-seed  or  a 
pin,  is  known  as  trminiatic ;  appendicitis  in  which  a  concretion 
is  the  assumed  cause  is  know^n  as  stercoral.  A  foreign  body 
may  produce  instant  perforation  at  the  site  of  the  body.  If 
impaction  of  a  foreign  body  or  concretion  occurs,  the  orifice 
of  the  appendix  is  closed,  the  circulation  is  soon  cut  off,  the 
secretions  are  retained,  the  coats  become  congested,  the  diver- 
ticulum enlarges  enormously,  microbes  multiply  with  great 
rapidity,  and  the  wall  of  the  congested  appendix  inflames  and 
may  become  gangrenous  or  ulcerated,  and  is  finally  perforated. 
Interference  with  the  blood-supply  of  the  appendix  will  pre- 
dispose to  appendicitis.  This  may  be  brought  about  by  twists, 
bruises,  adhesions,  concretions,  pressure,  or  bands ;  and  the 
psoas  muscle  may  play  a  part  in  the  production  of  these  con- 
ditions. In  women  appendicitis  is  occasionally  secondary  to 
tubo-ovarian  disease.  Appendicitis  is  rarer  in  w'omen  than 
in  men,  probably  because  the  appendix  of  a  woman  has  a 
better  blood-supply,  the  additional  supply  coming  through 
the  folds  of  the  appendiculo-ovarian  ligament.  Catarrhal 
conditions  of  the  intestine,  habitual  constipation,  indiges- 
tion with  flatulence,  predispose  to  appendicitis.  Some  hold 
that  catarrhal  appendicitis  may  result  from  extension  of  a  ca- 
tarrh of  the  colon,  and  may  also  arise  from  external  trauma- 
tism. If  before  perforation  the  appendix  adheres  to  the  cellu- 
lar tissue  behind  the  cecum,  cellulitis  or  abscess  without  peri- 
tonitis may  result.  When  appendicitis  goes  on  to  perforation, 
there  is  always  some  peritonitis  ;  but  if  the  steps  to  perfora- 

^  Progres  Medicale,  No.  19,  1S96. 


650  MODERN  SURGERY. 

tion  are  gradual,  the  peritonitis  may  be  local,  and  will  some- 
times by  formation  of  adhesions  make  a  barrier  between  the 
appendix  and  the  peritoneal  cavity  before  perforation  occurs. 
When  perforation  takes  place  suddenly  diffused  septic  perito- 
nitis is  inevitable.  Peritonitis  may  arise  without  perforation 
by  contiguity  of  structure  or  by  migration  of  the  bacterium 
coli  commune  through  the  congested  walls  of  an  obstructed 
appendix.  In  some  cases  perforation  takes  place  into  the 
peritoneal  cavity,  but  pus  is  circumscribed  by  matting  to- 
gether of  the  intestines  with  plastic  exudate.  The  appendix 
may  become  gangrenous  very  rapidly  or  after  some  time.  A 
case  of  appendicitis  in  which  gangrene  and  perforation  come 
on  very  quickly  is  spoken  of  as  fulminating  appendicitis.  In 
some  cases,  if  the  perforation  is  very  small  and  the  appendix 
is  swathed  in  lymph,  or  if  perforation  does  not  occur,  the  in- 
flammation may  subside.  Perforation  rarely  occurs  from 
liquid  pressure  or  from  the  pressure  of  concretion  ;  it  is 
generally  due  to  ulceration  produced  by  the  action  of  micro- 
organisms. Appendicitis  which  subsides  may  at  any  time 
recur,  and  the  life  of  the  patient  is  under  constant  menace. 
An  enormous  number  of  people  have  had  appendicitis.  Toft 
recorded  500  autopsies,  and  in  36  per  cent,  of  them  there 
were  positive  signs  of  past  attacks.  The  disease  is  occasion- 
ally unsuspected  during  life.  These  facts  prove  that  the  dis- 
ease may  subside  without  the  aid  of  surgery. 

Porms  of  Appendicitis. — In  what  is  known  as  appendicu- 
lar colic  the  appendix  is  temporarily  obstructed  because  of 
swelling  of  the  mucous  membrane  of  the  outlet,  and  the 
stercoral  contents  are  retained  in  the  diverticulum.  This 
condition  is  called  by  Fergusson  "  constipation  of  the  appen- 
dix." It  is  not  appendicitis,  but  if  not  relieved  will  rapidly 
eventuate  in  appendicitis. 

Simple  parietal  or  catarrhal  appendicitis  is  not  limited  to 
the  mucous  membrane ;  hence  the  term  catarrhal  is  not 
strictly  correct.  Forty-eight  hours  after  the  mucous  coat 
begins  to  inflame  the  peritoneal  coat  will  probably  be  in- 
volved. In  simple  appendicitis  the  diverticulum  enlarges, 
fills  up  with  mucus,  and  its  coats  become  infiltrated  with 
inflammatory  exudate.  This  inflammation  may  undergo 
resolution  or  suppuration,  or  may  become  chronic.  In 
a  catarrhal  inflammation  secondary  to  catarrh  of  the  colon 
the  case  may  be  chronic  from  its  origin.  If  the  lumen  of 
the  appendix  is  gradually  obliterated,  the  condition  is  de- 
nominated obliterativc  appendicitis  (Senn).  This  progressive 
obliteration  may  result  from  repeated  attacks  of  inflamma- 


DISEASES  AND  INJURIES   OF  THE  ABDOMEN.       65  I 

tion  or  may  be  simply  a  degenerative  change.  In  appen- 
dicitis with  a  concretion  the  attack  may  subside,  the  fluid 
elements  may  be  absorbed  or  flow  back  into  the  bowel,  and 
resolution  of  the  exudate  may  take  place ;  but  if  the  con- 
cretion remains  in  the  appendix,  recurrence  is  probable. 
Recurrent  appendicitis,  it  is  said,  may  be  due  to  inordinate 
size  of  the  mouth  of  the  appendix,  making  of  this  diverticu- 
lum a  drag-net  for  foreign  bodies ;  but  it  is  more  probable  that 
it  is  due  to  smallness  of  the  opening,  so  that  it  quickly  closes 
and  converts  the  appendix  into  a  closed  vase  filled  with  septic 
material.  Suppurative  appendicitis  is  due  to  purulent  infiltra- 
tion of  the  walls.  Pus  in  the  lumen  is  not  purulent  appen- 
dicitis. Gangrenous  appendicitis  is  a  moist  or  septic  gangrene, 
due  to  interference  with  the  circulation  and  to  tissue-destruc- 
tion by  the  action  of  micro-organisms.  Perforations  occur, 
and  they  are  often  multiple.  The  entire  appendix  may  slough 
off.  Interference  with  circulation  may  be  caused  by  an  ob- 
struction, by  a  bend,  or  twist,  or  bruise  of  the  appendix,  or 
by  the  action  of  virulent  organisms  on  an  appendix  whose 
tissue-resistance  is  lowered  by  injury  or  disease.  In  gan- 
grenous cases  the  vessels  of  the  meso-appendix  are  usually 
obstructed  by  thrombi  or  the  changes  of  arteritis  (Van  Cott). 

Fowler  suggests  the  follow^ing  classification  of  cases  of 
appendicitis:  (i)  endo-appendicitis ;  (2)  parietal  appendicitis; 
(3)  peri-appendicitis  ;  (4)  para-appendicitis. 

As  a  matter  of  fact,  appendicitis  is  always  one  disease, 
which  varies  in  intensity,  and  it  is  useless  to  divide  it  into  a 
great  number  of  symptomatic  groups.  In  rare  instances 
appendicitis  is  due  to  tubercular  ulceration  and  typhoid 
ulceration.  Genuine  appendicitis  may  arise  during  typhoid 
fever. 

Symptoms. — In  what  is  known  as  appendicular  colic  there 
are  colicky  pain  about  the  umbiHcus  and  right  iliac  fossa,  nau- 
sea and  vomiting,  and  usually  constipation,  but  no  tenderness 
in  the  iliac  fossa  and  no  abdominal  rigidity.  This  condition,  if 
not  soon  relieved,  is  followed  by  the  evidences  of  inflamma- 
tion. The  symptoms  of  genuine  appendicitis  are  as  follows : 
in  some  cases  the  patient  feels  out  of  sorts  for  a  day  or  two. 
Constipation  is  very  generally  present,  but  in  rare  cases 
there  is  diarrhea.  The  sufferer  complains  of  anorexia,  dys- 
pepsia, flatulence,  colicky  pain,  and  a  feeHng  of  weight,  sore- 
ness, or  pain  in  the  right  iliac  fossa.  Nausea  is  often  present, 
and  vomiting  may  occur.  The  tongue  is  coated.  Examina- 
tion discovers  tenderness,  rigidity,  fullness,  and  pain  in  the 
right   iliac   fossa.     The  tenderness  is  most   marked   about 


652  MODERN  SURGERY. 

McBurney's  point.  There  is  moderate  fever,  and  the  pulse  is 
about  100  or  less.  The  patient  may  get  well,  the  symptoms 
gradually  passing  off.  He  may  get  gradually  worse.  The 
tenderness  increases  ;  the  pain  becomes  agonizing  and  radi- 
ates toward  the  umbilicus,  and  the  patient  draws  up  the 
right  leg  to  relieve  it.  Pressure  upon  the  left  side  often 
causes  pain  in  the  right  iliac  region,  A  rectal  or  vaginal 
examination  may  make  out  tenderness,  or  enable  the  surgeon 
to  feel  a  lump.  The  pulse  increases  in  frequency,  the  fever 
rises,  the  abdominal  distention  and  rigidity  become  more 
marked,  vomiting  begins  and  becomes  worse,  and  the  res- 
piration becomes  shallow  and  thoracic.  There  are  great 
thirst,  anorexia,  constipation,  and  mental  anxiety.  Absolute 
obstruction  sometimes  takes  place.  The  urine  is  scanty 
and  highly  colored.  Hiccoughs  develop.  If  the  inflammation 
continues  for  one  or  two  days,  swelling  is  often  observed 
in  the  right  iliac  fossa,  or  is  detected  by  a  vaginal  or  rectal 
examination,  or  by  bimanual  palpation,  or  by  examination 
under  ether.  It  is  not  wise  to  forcibly  palpate  in  acute  ap- 
pendicitis, as  it  may  cause  rupture.  If  the  appendix  is 
enlarged,  and  the  individual  has  a  thin  abdomen  which  is 
not  rigid,  it  is  often  possible  to  palpate  the  appendix.  Some- 
times it  may  be  felt  when  the  patient  is  anesthetized,  though 
it  could  not  be  detected  before. 

A  case  of  appendicitis  may  come  on  suddenly  with  pain,  pre- 
monitory symptoms  having  never  occurred.  There  are  nausea 
and  bilious  vomiting,  constipation,  and  distention  of  the  abdo- 
men. Such  attacks  are  not  to  be  considered  as  colic  from  the 
lodgement  of  a  calculus.  They  are  inflammatory,  and  are 
associated  with  fever  and  the  other  symptoms  previously 
set  forth.  Examination  detects  tenderness  in  the  right  iliac 
fossa.  The  point  of  greatest  tenderness  is  known  as  "  Mc- 
Burney's point,"  This  is  apt  to  be  about  two  inches  from 
the  anterior  superior  spine  of  the  ilium,  on  a  line  drawn  from 
the  spine  to  the  umbilicus.  Pain  at  McBurney's  point  is 
linked  with  local  muscular  rigidity  and  hyperesthesia  of  skin. 
Such  a  case,  like  the  former  cases  described,  may  get  well  or 
may  get  worse.  In  some  cases  all  the  symptoms  are  violent 
from  the  beginning,  the  attack  tends  to  linger,  and  is  followed 
by  persistent  soreness  of  the  appendix  and  harassing  digestive 
disturbances.  Any  case  of  appendicitis  may  become  suddenly 
desperately  grave  because  of  perforation  or  gangrene.  The 
temperature  falls,  hiccough  begins,  abdominal  distention,  pain, 
and  tenderness  become  marked  and  general,  and  the  pulse 
becomes  very  rapid.     In  some  cases  these  grave  symptoms 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.      653 

are  present  almost  from  the  start  (fulminating  cases).  A  sud- 
den perforation  produces  collapse,  and,  if  reaction  takes  place, 
suppurative  peritonitis  arises.  Peritonitis,  be  it  remembered, 
often  arises  without  either  perforation  or  gangrene  (Dieula- 
foy).  If  pus  forms,  it  may  be  unlimited  by  adhesion.  In 
such  cases  there  is  the  rapid  onset  of  fatal  peritonitis  and 
septicemia.  Pus  may  be  limited  by  adhesions  and  be  practi- 
cally extraperitoneal.  In  such  a  case  a  lump  is  felt  in  the 
right  iliac  region  ;  and  dusky  discoloration  and  edema  of  skin 
sometimes  exist.  In  an  abscess  case  there  are  usually  irregu- 
lar fever  and  sweating.  A  limited  collection  of  pus  may  be 
liberated  into  the  peritoneal  cavity  by  rupture  of  the  abscess- 
wall.  Such  a  rupture  may  be  caused  by  pressure  or  muscular 
effort,  and  it  gives  rise  to  shock,  and  is  followed  by  diffused 
peritonitis.  An  abscess  may  rupture  externally,  or  into  the 
vagina,  intestinal  tract,  or  bladder. 

Terminations. — Appendicitis  may  terminate  in  recovery, 
in  death,  or  in  a  condition  of  lowered  vitality,  renewed 
attacks  being  certain  to  occur.  Adhesions  may  form  as  a 
result  of  appendicitis,  general  peritonitis  may  arise,  the 
appendix  may  slough  or  become  perforated,  or  abscess  may 
ensue  upon  local  peritonitis.  Pylephlebitis  and  abscess  of 
the  liver  may  follow  appendicitis. 

Treatment. — In  appendicular  colic  give  a  saline  cathartic, 
apply  a  hot-water  bag  to  the  right  iliac  fossa,  and  watch  the 
development  or  abatement  of  the  symptoms  with  anxious 
care.  Many  surgeons  give  a  purgative  in  the  beginning  of 
a  case  of  even  undoubted  appendicitis.  This  plan  of  treat- 
ment was  begun  with  the  belief  that  an  inflammation  of  the 
appendix  was  associated  with  fecal  impaction  in  the  head  of 
the  colon,  an  idea  which  has  been  entirely  exploded.  It 
does  not  seem  safe  to  give  a  purgative  in  genuine  appen- 
dicitis, because  violent  peristalsis  and  increased  tension  may 
serve  to  produce  perforation.  In  mild  cases  leech  over  the 
right  iliac  fossa,  apply  an  ice-bag,  give  an  enema,  place  the 
patient  on  a  bland  liquid  diet,  administer  antipyrin  for  the 
pain,  and  maintain  rest  in  bed.  If  the  case  is  not  better  in 
thirty-six  hours,  operate.  If  it  becomes  worse  within  that 
time,  operate  at  once  (if  pulse  becomes  very  rapid,  if  fever 
rises,  if  sweats  are  observed,  if  temperature  is  very  oscil- 
lating, if  distention,  rigidity,  pain,  or  tenderness  become 
more  marked,  if  shock  arises).  In  any  severe  case  operate 
at  once.  Opium  should  not  be  used.  It  masks  the  symp- 
toms, makes  the  patient  feel  comfortable,  and  gives  a  false 
sense  of  security.     In  an  appendicitis  even  with  slight  symp- 


654  MODERN  SURGERY. 

toms  many  surgeons  maintain  that  an  operation  should  be 
performed  at  once,  because  the  mildness  of  the  symptoms 
is  no  assurance  that  even  in  an  hour  or  two  gangrene  or  per- 
foration will  not  occur.  Early  operation  is  comparatively  safe ; 
operation  after  perforation,  gangrene,  or  septic  peritonitis 
arises  must  be  done,  but  it  is  not  unusually  futile.  Murphy, 
Deaver,  and  others  operate  at  once  in  every  case.  Keen,  Senn, 
White,  Grieg  Smith,  and  others  strongly  oppose  this  plan. 
Other  surgeons,  in  a  first  attack,  if  the  symptoms  are  mild, 
wait  and  temporize,  apply  a  hot-water  bag  over  the  right  iliac 
fossa  to  favor  plastic  exudation,  and  give  opium  in  full  doses. 
Some  begin  treatment  by  the  administration  of  salines,  apply 
an  ice-bag  over  McBurney's  point,  and  after  a  free  movement 
of  the  bowels  give  opium  and  keep  the  patient  on  liquid 
diet.  If  the  symptoms  become  worse,  they  recommend 
operation.  The  author  does  not  believe  that  it  is  proper 
to  always  operate.  Such  a  rule  makes  decision  easy,  but 
not  of  necessity  right.  In  a  case  with  severe  symptoms 
operate  at  once,  but  in  an  ordinary  mild  case  watch  the 
patient  for  a  few  hours.  McBurney  says,  if  six  hours  after 
the  beginning  of  the  attack  the  patient  is  no  worse,  there  is 
no  pressing  danger,  and  if  in  twelve  hours  symptoms  are 
not  intensified,  they  will  soon  begin  to  abate ;  but  if  in  the 
twelve  hours  the  case  has  become  worse,  operation  is  neces- 
sary.^ It  is  well,  if  possible,  to  operate  in  an  interval  in 
preference  to  operating  in  an  attack.  McBurney  says,  if  in 
twenty-four  hours  from  the  onset  of  an  attack  the  severity 
of  the  symptoms  lessens,  it  is  usually  possible  to  wait  for  an 
interval ;  but  if  during  the  second  twenty-four  hours  the 
abatement  in  symptoms  has  not  gone  on  and  there  is  doubt 
as  to  the  condition,  operate  at  once.  It  is  not  safe  to  delay 
operation  in  a  pus  case,  hoping  that  the  pus  may  become 
well  limited.  It  may  become  limited,  but  it  may  instead  pass 
up  toward  the  liver  or  down  into  the  pelvis,  and  delay  is 
fraught  with  peril.  The  interval  operation  can  be  performed 
about  three  weeks  after  the  attack,  or  later.  If  there  has 
been  but  one  acute  attack,  there  may  never  be  another,  and 
operation  need  not  be  done  unless  tenderness  persists  or 
there  are  colicky  pain  and  tenderness  after  exercise.  But 
if  a  man  has  had  two  attacks,  he  is  certain  to  have  others, 
and  an  interval  operation  must  be  performed  (see  Opera- 
tion for  Appendicitis). 

^  yV".  Y.  Polyclinic,  Jan.  15,  1897. 


DISEASES  AND   INJURIES   OF   THE   ABDOMEN.       655 

The    Peritoneum. 

Peritonitis. — In  rare  instances  peritonitis  is  said  to  be 
primary,  following  a  cold ;  but  most  surgeons  doubt  this. 

Plastic  peritonitis  is  due  to  an  aseptic  cause  (traumatism 
or  chemical  irritation) ;  it  remains  limited,  and  is  really  a 
process  of  repair  rather  than  of  inflammation.  The  symp- 
toms of  plastic  peritonitis  are  local  pain,  tenderness,  and 
rigidity.  Fever  exists,  due  to  the  absorption  of  fibrin-fer- 
ment and  the  products  of  tissue-change ;  adhesions  form, 
which  may  be  either  temporary'  or  permanent.  Recovery 
is  the  rule.  The  treatment  comprises  saline  purgatives 
followed  by  rest,  a  liquid  diet,  and  local  heat  (hot-water 
bag  or  fomentations). 

Diffuse  septic  peritonitis  is  apt  to  destroy  life  even  before 
the  peritoneum  presents  any  marked  change.  Death  ensues 
from  the  absorption  of  toxic  alkaloids.  Septic  peritonitis 
may  arise  during  puerperality,  through  lymphatic  infection  ; 
it  may  be  due  to  infection  from  without  by  an  operation  or 
an  accident ;  to  perforation  of  an  ulcer ;  to  gangrene  of  a 
portion  of  the  intestine ;  to  rupture  of  an  abscess  into  the 
peritoneal  cavity ;  or  to  migration  of  micro-organisms 
through  a  damaged  wall  of  the  bowel.  It  is  made  mani- 
fest by  a  chill,  shock,  or  rapid  collapse  ;  veiy  rapid  pulse, 
which  is  at  first  wiry  and  later  gaseous  ;  a  temperature  which 
may  be  at  times  febrile,  but  which  is  apt  to  be  subnormal  or 
which  soon  becomes  so  ;  dvf  tongue,  delirium,  and  persistent 
vomiting.  Rigidity  may  exist,  and  also  intestinal  obstruction  ; 
often,  but  not  invariably,  there  is  distention.  In  puerperal  peri- 
tonitis or  septic  peritonitis  from  operation  there  is  often  no 
pain  ;  in  perforative  peritonitis  there  is  acute  pain.  Patients 
usually  (lie  within  five  or  six  days.  Treatment  is  rarely 
successful.  Stimulants  are  strongly  pushed.  The  patient 
is  fed  upon  liquids  (koumiss  especially).  The  abdomen  is 
opened  in  the  middle  and  also  upon  one  or  both  sides. 
Any  perforation  is  closed.  In  some  cases  a  suprapubic 
incision  is  also  made,  in  other  cases  an  opening  is  made  in 
the  loin.  In  a  woman  Douglas's  sac  is  opened  through 
the  vagina.  The  peritoneal  cavity  is  wiped  out  with  gauze 
pads  or  is  flushed  out  with  gallons  of  hot  normal  salt  solu- 
tion. Special  attention  is  given  to  cleansing  Douglas's 
pouch  and  the  space  between  the  liver  and  diaphragm. 
The  Avounds  are  left  open,  and  drainage  is  maintained  by 
strips  of  iodoform  gauze. 

In   fibrinoplastic   peritonitis    the   septic    organisms    are 


656  MODERN  SURGERY. 

fewer  or  less  virulent,  the  products  of  germ-action  are  lim- 
ited and  surrounded  by  adhesions,  and  circumscribed  sup- 
purative peritonitis  is  apt  to  arise. 

Suppurative  peritonitis  differs  clinically  from  septic  peri- 
tonitis in  the  fact  that  it  is  more  apt  to  be  circumscribed 
and  less  apt  to  be  fatal.  The  causes  of  both  are  identical. 
In  septic  peritonitis  death  occurs  from  absorption  of  tox- 
ins before  obvious  pathological  changes  occur  in  the 
peritoneum ;  in  suppurative  peritonitis  the  microbes  are 
fewer,  are  less  virulent,  or  vital  resistance  is  more  decided, 
and  suppuration  follows  marked  changes  in  the  peritoneum. 
In  suppurative  peritonitis  the  pyogenic  bacteria  are  always 
present,  and  there  exists  in  the  peritoneum  a  wound  or 
damaged  area  to  constitute  a  point  of  least  resistance. 

Symptoms. — Chilliness  or  a  rigor  is  common,  followed  by 
fever,  the  temperature  rising  to  102°  or  104°  ;  pain  is  intense, 
and  is  accentuated  by  motion  and  pressure ;  the  attitude  of 
the  patient  is  assumed  to  relieve  pain  (he  lies  upon  his  back, 
with  the  shoulders  raised  and  the  thighs  drawn  up) ;  there 
are  vomiting,  obstinate  constipation,  and  distention  and 
rigidity  of  the  abdominal  walls.  The  pulse  is  rapid ;  is  at 
first  wiry,  but  may  become  gaseous.  The  constipation  may 
be  due  either  to  tympanitic  distention  or  to  the  shock  of  a 
perforation  inhibiting  intestinal  peristalsis.  Vomiting  is  fre- 
quent. In  perforation  gas  often  passes  into  the  peritoneal 
cavity  and  obscures  the  liver-dulness  ;  in  tympanites  without 
perforation  the  liver  is  pushed  up  and  its  dulness  usually 
remains,  but  on  a  higher  level.  Pus  unconfined  by  adhe- 
sions will  gravitate  to  the  most  dependent  part  of  the  peri- 
toneal cavity.  Circumscribed  suppurative  peritonitis  presents 
the  signs  of  a  deep  abscess  (swelling,  dulness  on  percussion, 
local  rigidity,  irregular  temperature,  sweats,  and  possibly 
edema  of  the  belly-wall).  In  some  cases  of  suppurative 
peritonitis  there  is  no  tympanitic  distention  or  rigidity ;  in 
some  cases  there  is  no  fever,  and  a  subnormal  temperature 
may  even  exist.  The  high-tension  pulse  of  peritonitis  is  due 
to  the  tympanitic  distention  emptying  the  bowel-walls  of 
blood,  and  thus  increasing  the  amount  of  fluid  in  the  other 
vessels  of  the  body. 

Treatment. — In  the  beginning  of  ordinary  peritonitis  with- 
out perforation  give  a  saline  cathartic,  which  will  empty  the 
peritoneal  cavity  of  fluid,  will  favor  the  elimination  of  mi- 
crobes, and  will  combat  inflammation.  The  old-time  remedy 
was  opium,  but  Tait  proved  its  inefficiency,  and  showed  that 
it  masked  the  symptoms  and  often  created  a  false  sense  of 


DISEASES  AND   INJURIES   OF  THE  ABDOMEN.      657 

security  in  the  very  midst  of  imminent  dangers.  The  usual 
method  of  administering  salines  is  to  give  oj  of  Rochelle  salt 
and  .^j  of  Epsom  salt  every  hour  until  a  free  movement 
occurs.  This  treatment  will  often  cut  short  a  beginning- 
peritonitis,  and  will  frequently  prevent  a  peritonitis  after  an 
abdominal  operation.  Give  an  enema  of  turpentine  at  the 
same  time  as  the  saline.  If  this  treatment  fails,  open  the 
belly,  explore  for  the  causative  condition,  remedy  it,  flush, 
and  drain.  In  perforative  peritonitis  do  not  give  cathartics  : 
they  will  only  increase  the  extravasation  and  prevent  its  lim- 
itation by  lymph.  As  soon  as  the  patient  has  reacted  from 
the  shock  of  the  perforation  perform  a  laparotomy,  suture 
the  perforation,  flush  out  the  belly,  and  drain.  A  circum- 
scribed abscess  is  to  be  opened  and  the  primary  lesion  sought 
for  and,  if  found,  removed.  Do  not  tear  the  lymph-barriers 
in  an  attempt  to  find  the  primary  lesion ;  rather  let  it  go  un- 
discovered. Pack  iodoform  gauze  against  the  intestines  to 
reinforce  the  barrier  of  lymph,  and  insert  a  tube.  In  some 
cases  make  incision  for  drainage  in  the  opposite  side  of  the 
belly,  above  the  pubes  or  through  the  right  kidney  pouch. 
It  is  frequently  advisable  to  leave  the  wounds  open  and 
drain  with  iodoform  gauze.  Every  patient  with  peritonitis 
requires   stimulants  and  frequent  feeding  with   liquid  food. 

Tubercular  peritonitis  is  seen  by  the  surgeon  as  a  pri- 
mary local  tuberculosis,  though  it  occurs  also  as  an  associate 
of  phthisis  and  as  a  part  of  a  general  tuberculosis.  Abdom- 
inal section  with  or  without  drainage  cures  not  a  few  cases. 
Why  it  cures  is  doubtful.  Abbe  thinks  that  the  fluid  acts  as 
a  culture-medium  for  bacilli.  When  the  fluid  is  removed  the 
tissues  regain  their  powers  of  resistance,  and  the  inflammation 
which  follows  the  operation,  plus  the  vital  resistance  of  the 
tissues,  causes  fibroid  transformation  of  the  peritoneal  tuber- 
cles ;  but  aspiration  will  not  cure,  while  incision  will. 

Subphrenic  Abscess. — A  subphrenic  abscess  is  a  col- 
lection of  pus  beneath  the  diaphragm.  The  pus,  as  a  rule^ 
occupies  a  part  of  the  lesser  peritoneal  cavity ;  in  rare  in- 
stances it  is  extraperitoneal  (when  it  is  of  renal  origin) ;  in  some 
cases  it  is  contained  in  the  area  between  the  diaphragm,  car- 
diac end  of  the  stomach,  and  liver  or  spleen.  It  is  an  unusual, 
thing  for  such  an  abscess  to  break  into  the  general  cavity  of 
the  peritoneum,  but  it  may  break  into  the  pleural  sac  (Maydl). 

Causes. — Perforation  of  a  gastric  ulcer,  perforation  of  the 
gall-bladder  or  gall-ducts,  ulceration  of  the  duodenum,  disease 
of  the  liver,  spleen,  pancreas,  intestine,  appendix,  or  kidney,, 
hydatid  disease,  internal  injury,  metastasis,  external  injur}',. 

42 


658  MODERN  SURGERY. 

caries  of  rib,  or  disease  of  the  pleura  may  be  responsible 
for  a  subphrenic  abscess  (Maydl). 

Symptoms.  —  There  are  the  constitutional  symptoms 
of  suppuration  and  a  swelling  in  the  subdiaphragmatic 
region,  these  symptoms  ensuing  upon  one  of  the  causative 
conditions  before  mentioned.  In  many  cases  the  abscess- 
cavity  contains  gas  as  well  as  fluid.  Empyema  and  sub- 
phrenic abscess  resemble  each  other.  In  empyema  the 
upper  limit  of  the  fluid  is  concave ;  in  subphrenic  abscess  it 
is  convex.  In  empyema  the  flow  of  pus  through  an  aspirat- 
ing-needle  will  be  most  marked  during  inspiration ;  in  abscess, 
during  expiration — the  same  is  true  of  the  rush  of  gas.  In 
empyema  the  needle  does  not  oscillate ;  in  abscess  it  does.^ 
The  fact  that  an  abscess  contains  gas  is  shown  by  the  ex- 
istence of  a  tympanitic  percussion-note  over  a  part  of  the 
cavity  and  an  alteration  in  the  area  of  tympany  with  an 
alteration  in  the  position  of  the  patient.  An  abscess  of  the 
liver  does  not  contain  gas  and  alters  decidedly  the  outlines 
of  the  organ. 

Treatment. — Incision  and  drainage.  The  incision  in  some 
cases  may  be  made  through  the  abdominal  wall  (epigastric 
region,  iliac  region,  hypochondrium,  or  loin).  In  other 
cases  the  chest-wall  is  incised,  a  rib  is  resected,  the  pleura  is 
opened,  and  the  diaphragm  is  incised. 

The  Liver  and  Gall-bladder. 

Wounds  of  the  I/iver. — A  wound  of  the  liver  causes  vio- 
lent hemorrhage  which  is  usually  rapidly  fatal.  Such  a  wound 
is  apt  to  divide  bile-ducts  and  allow  of  the  escape  of  bile  into 
the  peritoneal  cavity.  Bile  if  sterile  will  do  Httle  harm,  but  if  it 
contains  organisms  will  produce  a  diffuse  peritonitis.  Patients 
do  not  always  die  from  a  serious  traumatism  of  the  liver. 
Some  recover  because  operation  has  been  performed.  Some 
few  recover  without  operation.  This  last  fact  is  proved  by 
reports  of  autopsies  in  which  scars  were  found  in  the  liver- 
parenchyma  (Nussbaum).  The  fatality  which  usually  ensues 
on  a  liver  injury  may  be  due  to  hemorrhage  or  peritonitis. 
If  a  surgeon  is  called  to  a  patient  suffering  from  wound  of 
the  liver,  he  must  open  the  abdomen  to  arrest  hemorrhage. 
In  a  penetrating  wound,  the  wound  in  the  abdominal  wall 
must  be  enlarged.  If  the  left  lobe  of  the  liver  is  wounded, 
or  if  the  question  as  to  which  lobe  is  wounded  is  uncer- 
tain, the   incision    should   be   median.      If  the    right   lobe 

^  Wharton  and  Curtis,  Practice  of  Surgery. 


DISEASES  A. YD   INJURIES   OF  THE  ABDOMEN.       659 

is  wounded,  make  a  curved  incision  along  the  line  of  the 
costal  cartilages.  In  some  cases  these  two  incisions  are 
joined/  The  convex  surface  of  the  liver  can  be  reached  by 
Lannelongue's  plan.  In  this  the  eighth,  ninth,  tenth,  and 
eleventh  costal  cartilages  are  resected  and  the  ends  of  the 
ribs  are  drawn  well  out.  When  the  wound  in  the  liver  is  found 
deep  sutures  of  catgut  should  be  inserted  in  the  liver  and 
the  capsule  should  be  stitched  with  fine  silk  (Schlatter).  If 
sutures  fail  to  arrest  hemorrhage,  stitch  the  liver  to  the 
belly- wall  and  employ  gauze  packing.  It  is  useless  to  try 
packing  without  first  attaching  the  li\-er,  because  pressure 
will  simplx'  push  the  liver  awaj'  and  will  not  stop  the  bleeding. 
The  cauter}-  should  not  be  used  if  the  wound  is  large,  be- 
cause, even  if  it  arrests  primary  hemorrhage,  secondaiy 
hemorrhage  will  be  apt  to  occur.  After  arresting  hemor- 
rhage wash  out  the  abdomen  with  hot  saline  fluid,  insert 
drainage,  and  close  the  abdominal  wound. 

Hydatid  cysts  of  the  liver  may  be  of  small  size  and  pro- 
ductive of  no  signs  or  symptoms  ;  or  may  be  of  large  size 
and  productive  of  the  signs  of  tumor.  In  the  epigastrium 
the  mass  may  be  prominent  and  may  fluctuate.  In  cyst  of 
the  right  lobe  the  dulness  is  found  in  the  axillary  line  and  the 
growth  encroaches  on  the  pleura.  In  a  large  c}'st  fluctu- 
ation and  hydatid  fremitus  ma}-  exist.  Hydatid  fremitus  is  a 
vibration  imparted  to  the  palpating  fingers  of  one  hand  when 
the  fingers  of  the  other  hand  knock  upon  the  cyst.  There 
may  be  no  discomfort  produced  by  even  a  large  cyst,  but,  as 
a  rule,  the  patient  suffers  from  a  dragging  sensation  in  the 
epigastrium,  and  pressure-symptoms.  Suppuration  in  the 
cyst  produces  the  symptoms  of  septicemia.  Rupture  of  the 
cyst  produces  shock,  and  even  death.  If  the  shock  is  re- 
covered from,  inflammation  arises,  the  area  of  which  depends 
upon  the  structures  damaged.  The  escape  of  even  a  small 
quantity  of  hydatid  fluid  into  the  peritoneal  cavity  produces 
urticaria  (hydatid  toxemia).  Aspiration  for  diagnostic  pur- 
poses is  not  advisable. 

Treatment. — Explorator}'  incision  may  be  necessaiy  to 
confirm  the  diagnosis,  and  the  operation  is  completed  at  this 
time.  After  exposing  the  cyst  it  is  packed  around  with  gauze 
and  a  trocar  is  introduced.  When  the  fluid  is  evacuated  the 
sac  is  incised  and  is  drawn  partly  through  the  wound  and  is 
attached  to  the  wound-margins.  The  endocyst  can  be  re- 
mov^ed  by  the  hand  or  by  irrigation.  A  large  drainage-tube 
is  introduced  (marsupiaHzation).     If  there  is  a  considerable 

1  See  Schlatter,  Beitrage  zur  Klinischen  Chirurgie,  Bd.  xv.,  Heft  ii.,  1896. 


66o  MODE  FN'  SURGERY. 

thickness  of  liver-tissue  over  the  cyst,  incise  the  liver  with 
the  cautery-knife.  Bond  devised  the  following  operation  for 
hydatid  cyst :  open  abdomen,  draw  up  the  cyst  and  surround 
it  with  gauze,  evacuate  contents  by  means  of  a  trocar  and 
cannula,  open  cyst,  turn  out  the  endocyst,  irrigate  cyst  with 
corrosive  sublimate,  dust  in  iodoform,  sew  up  the  cut  in  the 
cyst-wall,  drop  the  cyst  back  into  the  belly,  and  close  the 
abdominal  wound. 

Abscess  of  the  liver  may  be  due  to  the  presence  of 
ameba  coli.  An  abscess  so  caused  is  usually  single,  is 
known  as  a  tropical  abscess  because  of  its  frequency  in  hot 
climates,  and  is  usually  preceded  by  dysentery.  Such  an 
abscess  may  last  from  four  weeks  to  several  years.  Abscess 
of  the  liver  may  follow  upon  a  blow  in  the  hepatic  region,  or 
upon  suppuration  of  the  gall-passages.  It  may  be  metastatic, 
such  abscesses  being  multiple.  It  may  be  caused  by  foreign 
bodies  and  parasites  (Osier). 

Symptoms. — Osier  tells  us  that  the  solitary  abscess  in 
rare  instances  produces  no  symptoms  for  a  considerable  time, 
death  usually  ensuing  from  rupture.  As  a  rule,  the  liver  is 
distinctly  enlarged,  tender,  and  painful.  There  may  be  pain 
in  the  right  shoulder  and  back.  The  patient  loses  flesh ; 
there  is  a  septic  fever,  with  evening  rises  and  morning  remis- 
sions, and  severe  sweats,  except  in  very  chronic  cases,  when 
there  may  be  no  pyrexia.  The  skin  and  conjunctivae  show 
the  existence  of  slight  jaundice.  In  some  cases  there  is  diar- 
rhea, in  others  constipation.  An  abscess  may  lead  to  pyo- 
thorax,  may  break  into  the  lung,  may  rupture  externally,  or 
into  the  bowels,  stomach,  or  pericardial  sac.  In  pyemic 
abscess  the  liver  is  enlarged  and  tender,  there  is  slight  jaun- 
dice, and  the  general  symptoms  of  pyemia  are  present. 

Treatment. — In  tropical  abscess  make  an  exploratory  in- 
cision. If  the  abscess  is  adherent  to  the  parietal  peritoneum, 
and  is  not  covered  by  liver-substance,  at  once  proceed  to 
operation.  If  it  is  not  adherent,  or  is  covered  by  a  con- 
siderable layer  of  liver-substance,  stitch  the  visceral  peri- 
toneum to  the  parietal  peritoneum  and  postpone  further 
interference  for  forty-eight  hours.  The  operation  consists  in 
evacuating  the  pus  with  a  trocar  and  cannula,  incising  the 
abscess,  stitching  its  edges  to  the  edges  of  the  abdominal 
wound,  irrigating,  and  inserting  a  drainage-tube.  If  the 
abscess  is  covered  by  a  layer  of  liv-er-tissue,  after  locating  it 
with  a  cannula  open  into  it  with  a  cautery-knife  and  arrest 
hemorrhage  by  packing.  When  the  parietal  and  visceral 
peritoneum  are  adherent,  packing  will  arrest  bleeding;  if  they 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       66 1 

are  not  adherent  packing  will  only  push  away  the  movable 
liver  (John  O'Connor).  If  pyothorax  exists,  resect  a  rib, 
open  the  pleural  sac,  and  reach  the  abscess  in  the  liver  by  an 
incision  through  the  diaphragmatic  pleura  and  the  diaphragm. 
A  pyemic  abscess  should  not  be  operated  upon  unless  it 
points,  because  in  this  condition  multiple  abscesses  invariably 
exist. 

Displaced  I^iver. — This  condition  is  very  rare.  It  is 
due  to  relaxation  of  the  ligaments  of  the  liv^er.  It  may 
occur  alone,  but  is  more  often  a  part  of  a  general  abdominal 
relaxation  (Glenard's  disease).  The  liver  may  descend  into 
the  lower  abdomen. 

Treatment. — By  the  use  of  a  support.  If  this  fails  to 
give  relief,  open  the  abdomen  and  fasten  the  liver  to  the 
abdominal  wall  (hepatopexy).  Ramsay,  in  a  case,  rubbed 
the  upper  surface  of  the  liver  with  gauze  to  promote  ad- 
hesion, and  transfixed  the  round  ligament  with  a  suture, 
which  was  also  carried  around  the  cartilage  of  the  seventh 
rib.  Richelott,  Areilza,  and  Treves  have  operated  for  this 
condition. 

Gall-stones. — Gall-stones  are  formed  during  life  in  the 
gall-bladder,  or  bile-ducts,  by  the  agglutination  of  materials 
which  have  precipitated  from  bile.  The  conditions  of  the 
body  which  lead  to  the  formation  of  gall-stones  are  desig- 
nated by  the  term  cholelithiasis  (Brockbank).  But  one  stone 
may  be  present,  or  great  numbers  may  exist.  Solitary 
stones  may  be  nearly  round  or  cylindrical.  When  several 
stones,  or  many  stones,  exist  the  mutual  pressure  often  leads 
to  the  formation  of  facets  (Naunyn).  Brockbank  gives  the 
following  varieties  of  gall-stones  :  pure  cholesterin  stones, 
stra<:ified  cholesterin  stones,  common  or  gall-bladder  cal- 
culi, mixed  bilirubin  calcium  calculi,  pure  bilirubin  calcium 
calculi,  and  certain  rare  forms.  Gall-stones  usually  take 
origin  in  the  gall-bladder,  but  may  arise  in  the  common  duct, 
the  cystic  duct,  the  hepatic  duct,  or  the  smaller  ducts  of  the 
liver.  As  a  rule,  however,  calculi  in  the  common  or  cystic 
duct  were  not  formed  there,  but  were  transported  from  the 
gall-bladder  or  hepatic  ducts. 

Causes. — The  chief  causes  are  advancing  years,  insufficient 
exercise,  excess  of  nitrogenous  food,  gouty  tendencies,  ca- 
tarrhal inflammation  of  the  bile-ducts,  conditions  which  inter- 
fere with  the  emptying  of  the  gall-bladder,  typhoid  fever,  car- 
diac disease,  and  cancer  of  the  liver.  The  disease  is  more 
common  in  the  insane  than  in  the  mentally  sound,  and  in 
women  than  in  men.    The  special  liability  of  women  may  be 


662  MODERN  SURGERY. 

brought  about  by  tight  lacing,  pregnancy,  inactivity,  or 
movable  right  kidney.  There  are  two  forms  of  the  condi- 
tion to  be  considered.  The  acute  type,  due  to  efforts  made 
by  the  gall-bladder  or  duct  to  expel  the  concretion,  and  the 
chronic  condition,  in  which  a  calculus  is  lodged  for  a  long 
time,  or  in  which,  as  soon  as  one  calculus  is  passed  into  the 
intestine,  "another  begins  its  journey"  (Brockbank). 

Symptoms. — The  formation  of  a  stone  requires  several 
months,  and  during  the  antecedent  period  of  gastro-intes- 
tinal  catarrh,  "  the  prodromal  state  "  of  Kraus,  certain  symp- 
toms usually  exist,  viz.  :  constipation,  flatulence,  loss  of 
appetite,  migraine,  uneasy  sensations  in  the  epigastrium  or 
right  hypochondrium,  salldwness  of  skin,  slight  yellowness  of 
the  conjunctivae,  scantiness  of  urine,  which  excretion  is  satu- 
rated with  uric  acid,  and  may  after  a  time  contain  a  little  bile. 
If  this  condition  is  not  arrested  by  treatment  it  grows  worse. 
The  abdomen  becomes  decidedly  distended,  pressure  over 
the  stomach  or  liver  may  cause  distinct  uneasiness,  or  even 
pain ;  acid  indigestion  is  very  troublesome,  violent  attacks 
of  migraine  occur,  constipation  becomes  more  decided,  the 
feces  become  clay-colored,  gastralgia  may  occur,  the  skin  is 
apt  to  be  slightly  jaundiced,  itching  is  complained  of,  the 
patient  is  irritable  and  sleeps  poorly.  The  liver  is  found  to 
be  enlarged,  and  the  urine  contains  distinct  amounts  of  bile. 
When  the  patient  reaches  this  stage  gall-stones  are  very 
liable  to  form.  These  symptoms  may  pass  away  even  if  a 
concretion  forms.  It  is  quite  true  that  in  some  cases  a  stone 
exists  for  years  without  causing  trouble,  but,  as  a  rule,  it 
greatly  aggravates  the  condition.  When  a  stone  forms 
pain  is  apt  to  become  a  marked  feature  of  the  case.  A 
sense  of  pressure  or  of  soreness  in  the  hepatic  region  has 
added  to  it  sudden  and  transient  paroxysms  of  pain,  due 
to  the  passage  of  thick  bile  from  the  gall-bladder  and  small 
ducts,  or  of  gravel  from  the  small  ducts  urged  on  by  bile- 
pressure.  When  a  stone  begins  to  pass  from  the  gall-blad- 
der violent  colic  is  experienced.  Such  a  colic  usually 
comes  on  very  suddenly,  and  often  about  three  hours  after  a 
meal.  It  may,  however,  come  on  gradually,  the  patient 
complaining  greatly  of  flatulence.  The  pains  are  violent, 
spasmodic,  and  paroxysmal,  and  are  over  the  hepatic  and 
epigastric  regions,  "  radiating  upward  over  the  right  half  of 
the  thorax  "  (Kraus).  The  patient  is  profoundly  nauseated, 
and  usually  vomits,  the  abdomen  is  distended,  and  a  con- 
dition almost  of  collapse  is  soon  reached.  The  attack  lasts 
a  variable  time,  and  terminates  by  the  stone  passing  into  the 


DISEASES  AND  INJURIES   OF   THE  ABDOMEN.       663 

intestine  or  falling  back  into  the  bladder.  After  its  conclu- 
sion, if  the  feces  are  examined  carefully  during  several  days, 
the  stone  may  be  discovered.  The  fact  that  no  stone  is 
discovered  does  not  prove  that  no  stone  was  passed,  because 
a  cholesterin  stone  will  be  destroyed  in  the  intestinal  canal. 
Jaundice  almost  invariably  follows  the  attack.  If  the  stone 
is  impacted,  after  a  time  the  pains  become  less  violent,  but 
again  and  again  the  patient  suffers  from  aggravation  of  them. 
An  individual  may  get  about  with  impacted  stone,  but  again 
and  again  fierce  attacks  of  colic  occur,  and  the  patient  be- 
comes and  remains  deeply  jaundiced.  In  certain  cases 
attacks  of  gall-stones  are  accompanied  by  febrile  seizures 
resembling  malaria. 

Gall-stones  may  lead  to  suppurative  inflammation  of  the 
gall-bladder  or  bile-passages,  ulceration,  occlusion  of  the 
neck  of  the  gall-bladder,  dilatation  of  the  stomach  from  the 
formation  of  adhesions  which  kink  the  pylorus,  abscess,  peri- 
tonitis, empyema  of  the  gall-bladder,  and  cancer  of  the  gall- 
bladder. 

Treatment. — In  the  prodromal  stage  and  after  recovery 
from  an  attack  insist  on  the  patient  taking  considerable  out- 
door exercise.  Order  him  a  cold  sponge -bath  every  morn- 
ing, move  the  bowels  freely  every  day,  and  order  a  simple 
diet.  The  patient  should  avoid  all  highly  seasoned  foods, 
pastry,  rich  soups,  fatty  food,  cheese,  alcohol,  and  sweets. 
Alkalies  internally  are  of  value. 

During  the  attack  give  an  enema  and  apply  hot  turpentine 
stupes  over  the  hepatic  region.  Give  a  hypodermatic  injection 
of  morphin  and  atropin.  If  vomiting  does  not  occur,  let  the 
patient  drink  a  large  amount  of  warm  water  to  favor  it.  After 
the  attack  give  a  purgative. 

When  the  attack  has  terminated  look  carefully  for  any 
evidence  of  inflammatory  trouble  in  the  hepatic  region. 

In  certain  cases  operation  becomes  necessary.  Mayo 
Robson  advises  operation  in  the  following  cases :  ^  in  fre- 
quently recurring  biliary  colic  without  jaundice,  whether  the 
gall-bladder  is  enlarged  or  not ;  in  cases  of  enlargement  of 
the  gall-bladder  without  jaundice,  even  if  there  is  no  pain  ; 
in  persistent  jaundice  which  was  ushered  in  by  pain,  painful 
seizures  occurring,  whether  or  not  febrile  attacks  occur;  in 
empyema  of  the  gall-bladder ;  in  peritonitis  beginning  in 
the  gall-bladder  region ;  in  intrahepatic  abscess  and  in 
abscess  about  the  liver,  gall-bladder,  or  bile-ducts ;  in  some 
cases  where    the  stones    have  been  passed,  but  adhesions 

^  Mayo  Robson  on  the  Gall-bladder  and  Bile-ducts. 


664  MODERN  SURGERY. 

remain  and  produce  pain ;  in  fistula  cases ;  in  some  cases  of 
persistent  jaundice  due  to  obstruction  of  the  common  duct, 
although  there  may  be  a  possibility  of  cancer  existing ;  in 
phlegmonous  cholecystitis  and  gangrene  of  the  gall-bladder. 
Besides  these  conditions  which  may  be  produced  by  gall- 
stones, Robson  operates  for  wounds  of  the  gall-bladder, 
rupture  of  the  gall-bladder,  infective  and  suppurative  cholan- 
gitis, and  for  some  conditions  of  chronic  catarrh  of  the  bile- 
ducts  and  gall-bladder.^ 

The  common  operation  is  cholecystotomy  (or  cholecystost- 
omy),  which  consists  in  opening  the  gall-bladder,  removing  the 
stones,  and  closing  the  bladder  again,  or  in  making  a  fistula 
of  the  gall-bladder  (page  697).  If  calculi  exist  in  the  common 
duct,  it  may  be  possible,  after  celiotomy,  to  manipulate  them 
back  into  the  bladder.  In  some  cases  cholecystotomy  is  per- 
formed, or  a  fistula  is  made,  and  the  duct  and  bladder  are  fre- 
quently irrigated.  In  other  cases  the  stone  may  be  crushed 
by  the  fingers  manipulating  the  duct  and  the  concretion 
within  it.  The  duct  may  be  opened,  and  after  the  removal 
of  the  stone  closed  by  sutures  (choledochotomy).  If  the 
stone  is  impacted  near  the  outlet  of  the  duct,  the  duodenum 
is  incised  and  the  stone  removed  (choledocho-duodenot- 
omy).  A  dilated  bile-duct  may  be  anastomosed  to  the 
bowel  (choledocho-enterostomy)  or  to  the  surface  (chole- 
dochostomy).  The  obstruction  may  be  side-tracked  by 
anastomosing  the  gall-bladder  to  the  bowel  (cholecystenter- 
ostomy)  (page  697). 

The  Pancreas. 

Hemorrhage. — Pancreatic  hemorrhage  is  a  recognized 
cause  of  sudden  death.  The  symptoms  arise  without  warning, 
and  comprise  severe  pain,  nausea,  vomiting,  abdominal  ten- 
derness, distention,  great  restlessness,  constipation,  and  col- 
lapse. The  blood  may  collect  in  the  lesser  peritoneal  cavity, 
or  about  the  spleen  and  left  kidney  (Prince  and  F.  W. 
Draper). 

Acute  Pancreatitis. — Hemorrhagic  pancreatitis  occurs 
in  people  in  middle  fife,  and  especially  in  tipplers.  It  begins 
suddenly :  there  are  violent  pain,  nausea  and  vomiting,  moder- 
ate fever,  constipation,  distention,  and  rapid  collapse  (Regi- 
nald Fitz,  and  Osier  and  Welch).  Inflammation  of  the  pan- 
creas with  pus-formation  is,  as  a  rule,  more  chronic.     The 

^  Robson's  treatise,  from  which  the  above  is  taken,  is  a  valuable  exposition 
of  the  surgery  of  the  gall-bladder  and  bile-ducts. 


DISEASES  AND  INJURIES   OF   THE  ABDOMEN.       665 

symptoms  are  similar  at  the  beginning  of  the  attack  and  a 
septic  fever  develops.  In  some  cases  the  pancreas  becomes 
gangrenous. 

Treatment. — In  view  of  the  difficulty  of  distinguishing 
acute  pancreatitis  from  intestinal  obstruction  and  perforated 
ulcer  of  the  stomach,  in  any  case  where  either  of  these  con- 
ditions is  suspected  an  exploratory  laparotomy  is  indicated. 
Osier  speaks  of  cases  of  hemorrhagic  pancreatitis  in  which 
operation  was  followed  by  recovery. 

Cysts  of  the  pancreas  occasionally  follow  injury.  They 
are  due,  as  a  rule,  to  obstruction  of  the  orifice  of  the 
common  duct  or  of  the  pancreatic  duct  by  calculi,  tumor- 
pressure,  or  cicatricial  contraction.  These  cysts  may  grow 
rapidly  or  slowly.  They  usually  produce  considerable  pain 
and  gastro-intestinal  disturbance.  Examination  of  the  abdo- 
men maps  out  a  mass  which  is  usually  median,  is  elastic, 
and  is  dull  at  some  parts  but  resonant  at  others  (where  it  is 
crossed  by  the  colon).  The  fluid  of  the  cyst  is  apt  to  con- 
tain urea,  and  will  convert  starch  into  sugar. 

Treatment. — Tapping  is  contraindicated.  It  might  do 
much  damage.  In  Keen's  case,  if  an  aspirating-needle  had 
been  introduced  it  would  have  perforated  both  walls  of  the 
stomach.  Confirm  the  diagnosis  by  an  exploratory  incision. 
It  may  be  possible  to  extirpate,  but  it  is  better  to  incise  the 
cyst,  stitch  its  edges  to  the  belly-wall,  and  drain. 

The  Spleen. 

Wounds  and  Rupture. — A  wound  of  the  spleen  causes 
great  hemorrhage,  and  if  no  surgical  aid  is  offered  will 
rapidly  produce  death.  The  treatment  consists  in  celiotomy 
and  splenectomy. 

Rupture  of  the  spleen  produces  the  signs  and  symptoms 
of  intra-abdominal  hemorrhage.  It  can  only  be  certainly 
recognized  after  exploratory  celiotomy.  If  such  a  con- 
dition is  suspected  while  intravenous  saline  transfusion  is 
being  employed,  the  surgeon  opens  the  abdomen,  and  if 
the  spleen  is   ruptured,  removes  it. 

Abscess  of  the  spleen  is  a  rare  condition  which  is 
metastatic  in  origin.  Pain  is  felt,  and  enlargement  is  noted 
in  the  splenic  region,  and  the  symptoms  of  pyemia  exist. 
The  treatment  consists  in  incision  and  drainage. 

Wandering  Spleen. — The  spleen  may  wander  into  any 
part  of  the  general  peritoneal  cavity.  This  condition  is 
almost  never  met  with  except  in  women.     It  is  most  com- 


666  MODERN  SURGERY. 

mon  in  women  who  have  borne  children  (J.  Bland  Sutton). 
A  wandering  spleen  may  undergo  atrophy,  engorgement, 
or  axial  rotation  (J.  Bland  Sutton).  The  organ,  when  dis- 
placed, drags  upon  the  stomach,  producing  dilated  stomach ; 
it  may  interfere  with  the  bile-duct,  causing  jaundice ;  it  may 
cause  intestinal  obstruction  by  forming  adhesions,  or  may 
cause  uterine  retroflexion  or  prolapse  by  passing  into  the 
pelvis. 

J.  Bland  Sutton  says  this  condition  may  endanger  life,  as 
it  may  lead  to  rupture  of  the  stomach,  intestinal  obstruction, 
splenic  abscess,  or  splenic  rupture.^  A  wandering  spleen  can 
be  identified  by  the  fact  that  it  has  a  notch  upon  its  edge, 
and  can  be  pushed  about  the  abdomen.  When  this  con- 
dition exists  the  spleen  may  be  missed  from  its  normal 
situation.  Always  examine  the  blood  in  order  to  deter- 
mine if  leukemia  or  malaria  exists. 

Treatment. — Greiffenhagen  advocates  suturing  the  organ 
in  place  (splenopexy).  Most  surgeons  prefer  to  perform 
splenectomy.  Splenectomy  should  not  be  undertaken  if 
leukemia  exists.  In  such  a  case  apply  a  support  and  employ 
medical  treatment  for  the  existing  disease. 

Operations  upon  the  Abdomen. 

Abdominal  Section  (Celiotomy;  Laparotomy).  —  In 
opening  the  abdominal  cavity  for  exploratory  purposes  or 
to  gain  access  to  some  area  of  abdominal  or  pelvic  disease, 
the  patient  is  carefully  prepared  as  for  any  other  operation. 
The  instruments  required  depend  upon  the  nature  of  the  case. 
As  a  rule,  there  are  required  scalpels,  scissors,  a  dry  dis- 
sector, two  pairs  of  dissecting-forceps,  hemostatic  forceps, 
pedicle-forceps,  Hagedorn  needles,  calyx-eyed  intestinal  nee- 
dles, a  needle-holder,  drainage-tubes,  gauze  pads,  sponges, 
silk,  catgut,  silkworm-gut,  the  Paquelin  cautery,  an  electric 
light,  also  a  bag,  a  tube,  and  a  saline  solution  for  hypo- 
dermoclysis  or  transfusion.  Always  count  the  instruments, 
sponges,  and  pads,  and  write  down  the  number,  and  count 
them  again  after  operation.  This  rule  is  adopted  so  that  no 
instrument,  sponge,  or  pad  will  be  left  in  the  abdomen. 
The  abdominal  pads  and  sponges  are  not  used  when  dry. 
Dry  sponges  injure  the  peritoneum  and  favor  the  subse- 
quent development  of  adhesions  (Sanger).  The  pads  and 
sponges  should  be  wrung  out  in  normal  salt  solution  before 
using. 

*  British  Med.  Journ.,  Jan.  i6,  1897. 


DISEASES  AND  INJURIES   OF  THE  ABDOMEN.      667 

Operation. — In  some  cases  the  patient  is  placed  recum- 
bent, in  others  is  put  in  the  position  of  Trendelenburg  (Fig. 
201).     The  patient  is  to  be  care- 
fully protected  from  cold,  the  ex-  ^^Tx 
tremities  and  the  chest  are  cov-       «^m^,        \ 
ered  with  blankets,  and  sterilized           7^^-^    "  ^ 
sheets  are  placed  well  around  the          a        J\  *  -  J^^jh  "■ - 
field  of  operation.     The  surgeon      ^/___/As  j^^r^^^aia^^ip^'^ 
steadies  the  skin  of  the  belly  with      lllf     — ^"  -'^^ 
the  fingers  of  his  left  hand,  and,          f.g.  201, -The  Trendelenburg 
holding    the    knife    in    the    right 

hand,  makes  an  incision  about  two  inches  long.  This  in- 
cision is  often  made  in  the  middle  line  midway  between  the 
pubes  and  umbilicus,  but  may  be  in  the  semilunar  line,  in  the 
epigastric  region,  or  in  some  other  situation.  The  first  cut 
goes  to  the  aponeurosis.  Clamp  the  vessels.  Do  not  hunt  for 
the  linea  alba  below  the  umbilicus,  but  go  right  through  or  be- 
tw'een  the  recti  muscles.  Above  the  umbilicus  the  linea  alba 
is  very  distinct  and  the  surgeon  often  cuts  through  it.  Divide 
the  transversalis  fascia,  beneath  which  is  a  little  fat,  and  expose 
the  peritoneum.  The  latter  structure  is  recognized  by  its  glis- 
tening appearance,  by  the  ease  with  which  it  can  be  pinched 
up  between  the  finger  and  thumb,  and  by  the  readiness  with 
which  its  opposed  surfaces  may  be  made  to  glide  over  each 
other.  On  identifying  the  peritoneum,  catch  it  at  each  side  of 
the  incision  with  forceps,  raise  a  fold,  nick  it  with  a  knife,  and 
open  it  with  scissors  to  the  length  of  the  external  wound. 
To  prevent  stripping  of  the  peritoneum  a  good  plan  is 
to  anchor  it  to  the  belly-wall  with  a  stitch  on  each  side  of 
the  incision.  Through  the  wound  thus  made  the  abdomen 
and  its  contents  are  explored,  the  trouble  located,  and  deter- 
mination made  as  to  whether  or  not  further  operation  is  advis- 
able, and,  if  it  is  advisable,  what  form  it  shall  take.  It  may 
be  necessary  to  enlarge  the  wound.  This  is  done  by  placing 
the  index  and  middle  fingers  of  the  left  hand  in  the  belly, 
with  their  pulps  against  the  peritoneum,  in  the  line  where 
the  surgeon  will  cut,  to  serve  as  supports  to  the  scissors  and 
as  guards  to  intraperitoneal  structures.  The  scissors  are 
introduced  and  the  wound  is  enlarged  upward  around  the 
umbilicus  if  necessary.  As  soon  as  the  incision  is  complete 
it  is  a  good  plan  to  push  a  large  pad  into  Douglas's  pouch 
and  leave  it  there  until  the  operation  is  completed.  Slender 
adhesions  are  broken  off  with  the  finger  or  are  pushed  off 
with  gauze ;  firm  adhesions  are  tied  and  cut. 

The  toilet  of  the  peritoneum  is  important  after  the  opera- 


668  MODERN  SURGERY. 

tion  is  completed.  Following  a  clean  laparotomy,  when  but 
little  blood  has  flowed  into  the  cavity,  flushing  out  is  not 
required ;  if  much  blood  has  flowed  or  if  any  septic  matter 
has  passed  into  the  peritoneal  cavity,  after  removing  the 
sponge  from  Douglas's  pouch  flush  out  the  belly  thor- 
oughly with  hot  normal  salt  solution,  empty  out  most  of 
the  fluid,  but  let  a  pint  or  more  remain  in  the  abdomen. 
The  retention  of  saline  fluid  in  the  belly  minimizes  shock.  If 
there  is  widespread  infection,  eviscerate,  wipe  out  the  peri- 
toneum with  pads  soaked  in  hot  normal  salt  solution,  and 
wipe  the  intestines  carefully,  slowly  returning  them  as  they 
are  wiped.  Extravasated  septic  matter  is  apt  to  collect 
between  the  liver  and  diaphragm,  and  this  area  must  be 
carefully  wiped  or  irrigated.  In  some  cases  it  is  desirable 
to  drain  through  a  lumbar  incision.  Rutherford  Morrison 
has  pointed  out  that  on  the  right  side  a  lumbar  opening  will 
drain  a  pouch  which  holds  over  a  pint  of  fluid,  and  which, 
with  the  patient  recumbent,  is  the  most  dependent  portion 
of  the  peritoneal  cavity.  In  some  cases  a  drainage-opening  is 
made  on  each  side  of  the  belly  or  above  the  pubis.  In  septic 
cases  it  may  be  advisable  to  pack  with  iodoform  gauze  instead 
of  inserting  tubes.  Before  closing  the  wound  stop  hemor- 
rhage and  count  the  instruments  and  sponges.  In  most 
instances  drainage  is  not  needed,  but  it  must  be  used  in 
septic  cases  and  when  hemorrhage  has  been  severe.  We 
may  drain  by  a  rubber  tube,  strands  of  gauze,  or  a  glass 
tube.  If  a  glass  tube  iS  used,  it  is  introduced  at  the  lower 
angle  of  the  wound  and  reaches  the  bottom  of  the  pouch  of 
Douglas.  This  tube  is  repeatedly  emptied  during  the  prog- 
ress of  the  case  by  means  of  a  syringe.  In  closing  the 
wound  some  surgeons  close  the  peritoneum  with  a  continu- 
ous catgut  suture  and  close  the  belly-wall  with  interrupted 
sutures  of  silkworm-gut ;  some  operators  close  with  inter- 
rupted silkworm-gut  sutures,  including  peritoneum,  muscles, 
and  skin  in  each  stitch.  In  badly  infected  cases  the  wound 
is  often  kept  open.  Dress  with  aseptic  gauze  and  wood- 
wool, and  apply  a  flannel  binder. 

For  nonsuppurative  appendicitis  the  incision  is  two 
inches  internal  to  the  anterior  superior  iliac  spine  and  per- 
pendicular to  a  line  drawn  from  the  spine  to  the  umbilicus 
(Fig.  202).  The  incision  is  usually  one  and  a  half  to  two 
inches  in  length,  but  if  there  are  many  adhesions  it  may  be 
necessary  to  make  it  longer.  After  opening  the  perito- 
neum find  the  appendix  by  the  following  method :  follow 
the  parietal  peritoneum  outward  with  the  finger,  then  back- 


DISEASES  AND  INJURIES   GF  THE  ABDOMEN.       669 

ward,  then  inward ;  the  first  obstruction  it  encounters  is 
the  colon.  Pass  the  finger  down  to  the  head  of  the  colon, 
find  the  appendix,  usually  posterior  and  internal,  and  lift  it 
into  the  wound.    In  some  cases  it  will  be  advisable  to  deliver 


Fig.  202. — Resection  of  the  vermiform  appendix,  incision  through  the  abdominal  wall 
(Kocher)  :  a,  external  oblique  muscle  ;  h,  internal  oblique  muscle  ;  c,  aponeurosis  of  external 
oblique ;  d,  aponeurosis  of  internal  oblique  ;  e,  peritoneum  ;  f,  outer  border  of  rectus  abdom- 
inis muscle  (under  it  the  deep  epigastric  vessels). 

the  head  of  the  colon  from  the  belly ;  in  other  cases  this  will 
not  be  necessary.  Surround  the  appendix  with  iodoform 
gauze  to  prevent  infection.  In  most  cases  the  neck  of  the 
appendix  is  tied  with  strong  silk,  the  appendix  is  cut  off,  and 
the  stump  is  cauterized  with  pure  carbolic  acid  and  is  inverted 
into  the  coats  of  the  colon  by  Lembert  sutures.  An  excellent 
method  is  to  turn  up  a  cuff  of  peritoneum,  pull  down  the 
other  coats,  ligate  at  the  base,  cut  through  the  tube,  let  the 
musculomucous  stump  retract,  and  tie  or  suture  the  perito- 
neal cuff  over  the  stump.     This  plan  was  devised  by  Barker 


6/0 


MODERN  SURGERY. 


Fig.  203. — Barker's  technique 
of  operation  for  removal  of  the 
appendix. 


(Fig.  203).  Some  remove  the  appendix  by  an  elliptical  incision 
around  its  base,  and  close  the  colon-wound  by  Lembert  sutures. 
Some  invaginate  the  appendix  into  the  lumen  of  the  colon. 
If  there  is  no  abscess,  perforation,  or  gangrene,  and  no  pus 

within  the  appendix  or  in  its  coats, 
drainage  is  unnecessary ;  otherwise 
it  is  necessary.  If  the  operation  is 
in  a  distinct  interval,  pus  is  absent, 
and  we  can  proceed  without  appre- 
hension. Such  an  operation  should 
not  be  performed  until  three  weeks 
have  passed  since  the  acute  attack. 
If  there  is  any  question  as  to  the 
presence  of  pus,  surround  the  ap- 
pendix zone  with  iodoform  gauze 
before  breaking  down  adhesions  and 
liberating  the  appendix.  This  gauze 
protects  healthy  structures  from  in- 
fection. In  an  interval  case  McBur- 
ney  proceeds  as  follows :  he  makes  the  skin  incision  in  the 
direction  of  the  fibers  of  the  external  oblique  muscle,  sepa- 
rates the  fibers  of  this  muscle  by  blunt  dissection,  retracts 
them,  separates  the  internal  oblique  fibers  by  blunt  dissec- 
tion and  retracts  them,  separates  the  fibers  of  the  transver- 
salis  in  the  same  way  and  retracts  them,  opens  the  transver- 
salis  fascia  and  peritoneum.  No  muscle-fibers  are  cut,  and 
hernia  is  not  apt  to  follow.  Such  a  wound  is  closed  as  fol- 
lows :  a  continuous  catgut  suture  for  the  peritoneum,  suture 
of  kangaroo-tendon  for  transversalis  fascia,  muscles  restored 
to  place,  and  skin  closed  by  a  subcuticular  stitch. 

If  an  abscess  is  believed  to  exist,  make  an  incision  parallel 
with  Poupart's  ligament  and  over  the  area  of  dulness  on 
percussion  (Willard  Parker's  oblique  incision).  If  the  abscess 
is  adherent  to  the  belly-wall,  such  an  incision  will  not  enter 
the  free  peritoneal  cavity.  If  after  opening  the  abdomen  an 
abscess  is  thought  to  exist,  although  it  is  not  adherent  to  the 
belly-wall,  surround  the  abscess  with  gauze  before  opening  it. 
This  gauze  is  placed  under  the  margins  of  the  incision  in  the 
peritoneum  all  around  the  appendix  area ;  a  piece  is  carried 
toward  the  pelvis  and  another  piece  toward  the  liver.  Over- 
lay this  gauze  with  gauze  pads  (Van  Hook).  Adhesions  are 
broken  through  with  the  finger,  and  when  pus  appears  it  is 
at  once  wiped  away.  If  the  appendix  lies  loose  in  the 
abscess-cavity,  if  it  is  sloughed  off  or  but  loosely  attached 
to  the  abscess-wall,  remove  it.     If  the  appendix  is  firmly 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.      6/1 

fixed  in  the  abscess-wall,  do  not  remove  it.  To  remove  it 
under  these  circumstances  may  rupture  the  wall  and  allow 
pus  to  enter  the  peritoneal  cavity  where  it  is  not  protected 
by  pads  and  gauze.  Deaver,  Murphy,  and  others  tell  us  to 
alwa\-s  try  to  remove  the  appendix.  We  do  not  believe 
this  to  be  a  safe  rule  to  follow.  To  insist  on  removing  the 
appendix  may  cause  death.  When  the  appendix  is  left 
it  usually  sloughs  away.  It  is  true  a  fecal  fistula  may  result, 
but  this  usually  heals  spontaneously.  Even  if  it  does  not 
heal  the  surgeon  acted  properly,  because  a  fecal  fistula  may 
be  remedied  by  another  operation,  but  there  is  no  remedy 
for  death.  There  are  very  few  cases  on  record  where  an 
appendix  has  subsequently  given  trouble  when  left  after 
operation.  When  Deaver  decides  to  remove  such  an  appen- 
dix he  makes  an  incision  in  the  median  line  of  the  abdomen, 
packs  around  the  periphery  of  the  abscess  with  gauze,  opens 
the  abscess,  disinfects,  inserts  drainage,  and  then  removes  the 
surrounding  gauze  and  closes  the  median  incision.  Irriga- 
tion should  not  be  employed  in  appendicular  abscess.  The 
force  of  the  stream  may  break  down  barriers  of  lymph  and 
spread  infection.  After  the  evacuation  of  the  pus,  whether  the 
appendix  was  removed  or  not,  take  out  the  pads,  but  leave 
the  long  strands  of  iodoform  gauze  in  place  (Van  Hook). 
Introduce  iodoform  gauze  into  the  abscess-cavity  and  insert 
a  rubber  tube,  partially  suture  the  wound,  and  dress  with  dry 
gauze.  In  forty-eight  hours  all  the  gauze  is  removed  and 
fresh  pieces  are  inserted  for  drainage.  After  this  the  gauze 
drain  is  changed  daily.  An  interval  case  should  be  up  and 
about  in  from  ten  days  to  two  weeks  after  operation.  An 
abscess  case  may  require  a  much  longer  time  for  complete 
recovery,  and  a  fecal  fistula  sometimes  results  in  cases  in 
which  the  appendix  was  not  removed.  Morris  maintains 
and  proves  that  these  large  pieces  of  iodoform  gauze  some- 
times cause  intestinal  obstruction  and  sometimes  iodoform- 
poisoning,  but  the  risk  must  be  taken. 

Bnterorrhaphy,  or  Suture  of  the  Intestine. — Sur- 
gical opinion  has  greatly  altered  in  regard  to  this  oper- 
ation since  the  day  when  John  Bell  wrote  his  famous  attack 
on  Benjamin  Bell.  John  Bell  said :  "  If  in  all  surgery  there 
is  a  work  of  supererogation,  it  is  this  operation  of  sewing  up 
a  wounded  gut."  To-day  we  know  that  if  in  all  surgery 
there  is  a  proceeding  of  imperativ^e  necessity,  it  is  the  sewing 
up  of  a  wound  in  the  intestine.  To  perform  this  operation 
take  fine  sterile  silk  and  thread  a  thin,  round,  straight  calyx- 
eyed  needle  with  it  (Fig.  204).     This  needle  is  very  useful, 


6/2 


MODERN  SURGERY. 


as  it  can  be  threaded  rapidly  by  pushing  the  calyx  eye  down 
upon  the  silk  thread  while  the  latter  is  kept  taut.  Lemberfs 
suture  (Fig.  205,  a)  is  at  right  angles  to  the  wound.     It  goes 


Fig.  204. — Eye  of  the 
calyx-eyed  needle. 


Fig. 205 


— Enterorrhaphy  :  a,  Lembert's  suture;  b,  Dupuytren's 
suture. 


down  to,  but  not  through,  the  mucous  membrane.  It  is 
formed  by  picking  up  a  fold  of  the  intestine  (one-twelfth 
to  one-eighth  of  an  inch  wide)  one-eighth  of  an  inch  from 
the  edge  on  one  side  of  the  wound,  passing  the  needle 
through,  picking  up  a  fold  on  the  opposite  side  of  the 
wound,  and  passing  the  needle  through.  On  tying  the 
threads  the  serous  membrane  is  inverted  and  peritoneum 
is  brought  into  contact  with  peritoneum.  For  many  years 
it  was  taught  that  this  suture  should  include  only  the  serous 
coat,  but  Halsted,  in  1887,  showed  that  it  must  include  the 
tough  submucous  coat.  The  submucous  coat  is  strong,  and 
will  hold  a  suture.     The  other  coats  are  thin,  tear  easily,  and 


Fig.  206. — Cushing's  right-angled  suture  (Senn). 

will  not  hold  a  suture.  So  thin  are  the  coats  that  a  surgeon 
could  not  suture  the  serous  coat  alone  were  he  to  try. 
Sutures  which  include  both  muscular  and  serous  coats 
tear  out  easily.  The  needle  should  catch  up  the  submu- 
cous coat,  but  should  not  penetrate  the  intestine.^     Dupuy- 

1  Halsted,  Am.  Jour.  Med.  Sciences,  Oct.,  1887. 


DISEASES  AND  INJURIES   OF   THE  ABDOMEN.       673 


trc7i's  suture  (Fig.  204,  b)  is  simply  a  continuous  Lembert 
suture  running  obliquely  across  the  wound.  Cusliing's  7'igJit- 
anglcd  suture  (Fig.  206)  is  a  continuous  suture  catching  up 
the  submucous  coat  and  serving  to  invert  the  serous  layer. 
Halsted's  mattress  or  quilt  su- 
ture is  shown  in  Fig.  207.  Each 
stitch  picks  up  the  submucous 
coat.  Mattress  sutures  do  not 
tear  out  easily,  they  oppose 
evenly  considerable  surfaces,  and 
do  not  constrict  the  tissue  as 
much  as  Lembert  stitches.  The 
Czerny-Lenibert  suture  is  a  suture 
passed  through  the  serous  mem- 
brane on  one  side  of  the  wound, 
made  to  perforate  the  mucous 
membrane,  and  to  emerge  at  a 
corresponding  point  of  the  serous 
membrane.  A  Lembert  suture 
is  added  (Fig.  208).  As  at  present  used,  the  Czerny  suture 
is  carried  to,  but  not  through,  the  mucous  membrane.     Gus- 


-.: ) 


Fig.  207. — A,  Halsted  sutures  untied; 
B,  Halsted  sutures  tied  and  serous  sur- 
face inverted. 


Fig.  208. — Czerny-Lembert  suture. 


Fig.  209.- 


-Czerny-Lembert  suture  as  at 
present  used. 


Fig.  210. — Gussenbauer's  suture. 


senbauer's  is  similar  to  the  Czerny-Lembert  suture,  except 
that  it  applies  the  Czerny  and  the  Lembert  with  one  suture, 
43 


6/4  MODERN  SURGERY. 

and  this  suture  does  not  pass  through  the  mucous  mem- 
brane (Fig.  210).      Wolfler's  suture  unites  broad  layers  of  the 

serous  coat,  the  knots  being  tied 
internally  (Fig.  211).  Senn  says 
that  after  suturing  a  large  wound 
of  the  stomach  or  of  intestine  a 
strip  of  omentum  ought  to  be 
laid  over  the  wound  and  fastened 
by  catgut  sutures  (omental  graft). 
These  grafts  adhere  and  are  a 
safeguard  against  leakage.  For 
other  methods  of  enterorrhaphy, 
Fig.  211'— Wolfler's  suture.  sec  lutcstinal  Rcscction  and  Anas- 

tomosis. 
Digital  Dilatation  of  Pylorus  for  Cicatricial  Ste- 
nosis (I/Oreta'S  Operation). — For  a  week  before  operation 
feed  the  patient  by  enemata  supplemented  by  the  stomach 
administration  of  peptonized  milk,  and  wash  out  the  stomach 
once  a  day.  A  few  hours  before  operation  wash  out  the 
stomach  again.  Place  the  patient  recumbent  and  administer 
ether.  Make  a  vertical  incision  in  the  linea  alba.  The  in- 
cision begins  one  inch  below  the  ensiform  cartilage  and 
should  be  five  inches  in  length.  When  the  peritoneum  has 
been  opened  the  stomach  is  drawn  out  of  the  wound,  any 
adherent  omentum  is  separated,  and  the  pylorus  is  carefully 
examined.  The  stomach,  after  being  surrounded  with  gauze 
pads,  is  opened  near  the  center  of  its  anterior  surface,  "  but 
rather  nearer  to  its  pyloric  end  "  (Jacobson). 

Insert  the  index  finger  through  the  stomach  wound  and 
follow  that  with  the  middle  finger.  The  pylorus  can  be  well 
dilated  by  separating  the  fingers.  If  the  stenosis  is  so  tight 
as  to  prevent  the  entry  of  a  finger,  first  introduce  a  pair  of 
hemostatic  forceps  and  open  the  blades  a  little  when  they 
are  within  the  lumen  of  the  constricted  area.  The  wound  in 
the  stomach  is  closed  by  Halsted  sutures  of  silk  and  the 
abdominal  wound  is  closed. 

Pyloroplasty  (Heineke-Mikulicaj  Operation). — Pre- 
pare the  patient  as  for  Loreta's  operation.  Open  the  ab- 
domen in  the  middle  line.  Draw  up  the  pylorus  as  well  as 
possible  and  pack  hot  moist  gauze  pads  around  it;  make  an 
incision  through  the  stricture  and  in  a  direction  correspond- 
ing to  the  long  axis  of  the  stomach  and  bowel.  Catch  an 
aneurysm-needle  under  the  upper  margin  of  the  incision  and 
draw  it  up,  and  an  aneurysm-needle  over  the  lower  margin 
and  draw  it  down.     The  effect  of  traction  is  to  convert  the 


DISEASES  AND   INJURIES   OF  THE  ABDOMEN       ^J^ 

transverse  wound  into  a  vertical  one.  The  sutures  are  ap- 
plied so  as  to  maintain  the  wound  in  a  vertical  line.  The 
mucous  membrane  is  sutured  with  a  continuous  suture  of 
silk,  and  interrupted  Halsted  sutures  of  silk  close  the  peri- 
toneal and  muscular  coats. 

Pylorectomy  (Bxcision  of  the  Pylorus). — Prepare 
the  patient  as  directed  above.  A  removal  of  any  portion  of 
the  stomach  constitutes  a  gastrectomy,  and  pylorectomy  is  a 
gastrectomy  in  which  the  pylorus  is  removed.  The  best  in- 
cision through  the  abdominal  wall  is  transverse  over  the  mid- 
dle of  the  tumor.  A  small  incision  is  made  first  to  permit  of 
exploration,  and  if  the  growth  is  found  to  be  removable  the 
incision  is  enlarged.  The  center  of  the  incision  is  over  the 
most  prominent  part  of  the  tumor,  and  the  direction  of  the 
incision  corresponds  with  the  long  axis  of  the  pylorus. 
Draw  the  tumor  into  the  wound,  and  tuck  pads  about  the 
stomach  and  the  pylorus  to  catch  extravasated  fluids.  Free 
the  pylorus  ;  incise  between  forceps  the  great  omentum  near 
the  greater  curvature  of  the  stomach,  and  ligate  each  end  in 
segments ;  treat  the  lesser  omentum  in  the  same  manner. 
The  greater  and  the  lesser  omentums  are  divided  only  to  an 
extent  sufficient  to  permit  removal  of  the  growth.  Repack 
the  gauze  pads  and  tie  a  rubber  tube  around  the  duodenum 
below  the  growth.  In  making  the  excision  remember  that 
the  stomach-wound  will  be  much  larger  than  the  duodenal 
wound,  and  a  special  method  of  suturing  will  be  required  to 
approximate  the  two  wounds  in  size.  The  lines  of  incision 
are  shown  in  Fig.  212.  The  stomach  is  cut  with  scissors 
until  two-thirds  of  its  depth  is  divided,  and  the  organ  is 
washed  out.  After  stopping  hemor- 
rhage this  cut  is  closed  by  a  contin- 
uous suture  for  the  mucous  membrane 
and  by  Halsted  sutures  for  the  other 
coats.  The  remaining  portion  of  the 
stomach  is  cut  through.  The  duo- 
denum is  cut  through  its  upper  half 
below  the  growth,  and  is  fastened  to 
the  stomach  by  Halsted  sutures  at  the  '^"  ^"■~~  ^  oreaomy. 

upper  border  and  Wolfler's  sutures  at  the  posterior  borders, 
Wolfler's  sutures  are  applied  from  inside ;  pierce  all  the 
coats,  and  bring  broad  layers  of  the  serous  coat  into  appo- 
sition. The  remainder  of  the  duodenum  is  cut  through, 
and  its  anterior  and  inferior  parts  are  united  to  the  stomach 
by  a  double  row  of  sutures,  as  set  forth  above  (Fig.  212), 
Stitch  the  edges  of  the  cut  omenta  to  the  stomach,  cleanse 


6/6 


MODERN  SURGERY. 


the  parts,  replace  the  stomach,  close  the  abdominal  incision, 
and  dress  the  wound.  Give  nothing  by  the  mouth  for 
twenty-four  hours.  Thirst  can  be  relieved  by  enemata  of 
water  or  by  the  hypodermatic  injection  of  boiled  water. 
After  twenty-four  hours  begin  with  stomach-feeding,  start- 
ing with  dessertspoonful-doses  of  peptonized  milk  every 
hour.  Another  method  of  performing  pylorectomy  is  to 
excise  the  growth  as  directed  above,  suture  the  opening  in 
the  stomach,  and  implant  the  duodenum  in  the  anterior  or 
posterior  wall  of  the  stomach,  making  an  incision  through 
the  stomach-wall  to  permit  of  it.  Kocher  advocates  implan- 
tation of  the  duodenum  in  the  posterior  wall  of  the  stomach. 
Kocher's  method  of  pylorectomy  is  shown  in  Figs.  213,  214. 


Fig.  213. — Kocher's  method  of  pylorectomy :  L,  liver;  D,  duodenum;  P,  pylorus; 
C,  carcinoma;  T  C,  transverse  colon;  a,  separation-place  of  the  ligature  gastrocolicum ; 
i,  separation-place  of  the  lesser  omentum;  c,  separation-line  of  the  stomach;  d,  place  where 
the  stomach  is  kept  closed  by  the  middle  and  index  fingers. 

The  junction  between  the  duodenum  and  the  posterior  wall 
of  the  stomach  may  be  effected  by  a  large  Murphy  button. 

Gastrototny. — This  term  is  used  to  designate  the  opera- 
tion of  opening  the  stomach  for  the  accomplishment  of  some 
purpose,  and  immediately  closing  the  incision  in  the  gastric 
wall  when  that  purpose  is  accomplished.     Gastrotomy  may 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       677 

be  performed  to  permit  of  the  removal  of  foreign  bodies,  of 
exploration  of  the  stomach  and  its  extremities,  of  divulsion 
of  the  pyloric  orifice,  of  the  treatment  of  an  esophageal 


Fig.  214.  — Kocher's  method  of  pylorectomy  :  D,  duodenum  at  the  posterior  wall;  a, 
continuous  suture  of  the  peritoneum  ;  b,  posterior  line  of  peritoneal  continuous  suture  of  the 
ring  ;  /,  assistant's  thumb  pressing  the  stomach  against  the  duodenum  so  as  to  close  its  lumen  ; 
/,  incision  in  the  posterior  gastric  wall. 

stricture,  or  a  stricture  of  the  cardiac  orifice  of  the  stomach, 
or  of  the  removal  of  a  foreign  body  in  the  esophagus. 

The  patient  is  prepared  as  for  pylorectomy.  The  incision 
may  be  vertical  in  the  middle  line  or  identical  with  the  in- 
cision for  pylorectomy.  If  a  large  foreign  body  can  be  felt, 
the  incision  is  made  directly  over  it  (Jacobson).  When  the 
peritoneal  cavity  is  opened  the  surgeon  decides  as  to  the 
point  where  the  stomach  is  to  be  incised,  and  draws  this  por- 
tion out  through  the  wound,  packing  gauze  pads  under  and 
around  it.  The  stomach  is  opened  by  means  of  scissors,  the 
cut  being  at  a  right  angle  to  the  long  axis  of  the  viscus 
(Jacobson).  Any  bleeding  vessel  is  ligated  with  catgut.  The 
purpose  for  which  the  stomach  was  opened  is  now  to  be  car- 
ried out,  the  interior  of  the  stomach  and  the  surface  of  the 
extruded  portion  are  irrigated  with  hot  salt  solution,  and  the 
stomach-wound  is  sutured  with  silk.  A  row  of  deep  sutures 
is  introduced.  These  sutures  pass  through  all  the  coats.  A 
row  of  Halsted  sutures  is  then  inserted.  The  abdominal 
wound  is  closed  without  drainage. 


6;8 


MODERN  SURGERY. 


Gastrostomy  is  the  making  of  a  permanent  gastric  fistula, 
through  which  opening  the  patient  can  be  fed.  The  opera- 
tion is  employed  in  cases  of  esophageal  obstruction.  The 
surgeon  must  endeavor  to  perform  an  operation  which  will 


i§: 


Fig.  215. — Witzel's  method  for  gastros- 
tomy, showing  application  of  sutures  in 
wall  of  stomach,  embedding  tube  ob- 
liquely therein. 


Fig.  216. — Sutures  tied,   completely  embed- 
dmg  tube  for  some  distance. 


not  permit  of  leakage.  Prepare  the  patient  as  for  gastrotomy. 
In  Witzel's  method  an  incision  is  made  four  inches  long,  run- 
ning to  the  left  from  the  middle  line,  just  below  the  border 
of  the  ribs.  After  opening  the  peritoneal  cavity  seize  the 
stomach,  bring  it  out  of  the  wound,  and  pack  gauze  around 
it.  Introduce  a  rubber  tube  into  the  stomach  and  enfold  it 
by  a  double  row  of  Lembert  sutures  (Figs.  215,  216).  This 
tube  should  be  five  inches  long  and  of  the  same  diameter  as 
a  No.  25  French  bougie.  The  opening  in  the  stomach  is  to- 
ward the  cardiac  extremity,  the  tube  is  placed  parallel  with 
the  belly-wound,  and  the  outer  end  of  the  tube  emerges  in 
the  median  line.  The  stomach  is  returned,  and  is  stitched 
by  three  sutures  to  the  abdominal  wall.  The  tube  is  retained 
in  place  by  a  catgut  stitch  through  the  wall  of  the  tube  and 
the  stomach-wall.     The  abdominal  incision  is  sutured  and  a 


DISEASES  AXD  IXJURIES   OF  THE  ABDOMEN.       679 


clamp  \s,  placed  on  the  tube.  When  the  patient  is  fed  a  fun- 
nel is  slipped  into  the  tube,  the  clamp  is  removed,  and  liquid 
food  is  poured  into  the  funnel.  After  the  wound  heals  it  is 
not  necessan-  to  permanently  retain  the  tube.  It  is  passed 
when  the  patient  desires  food.  Kader  has  modified  Witzel's 
method.  A  small  incision  is  made  in  the  stomach  and  a  tube 
is  introduced.  Two  Lembert  sutures  are  passed  so  as  to 
form  a  fold  on  each  side  of  the  tube  and  turn  the  stomach- 
wall  inward  around  the  tube.  Lembert  sutures  are  inserted 
in  the  furrow  on  each  side  of  the  tube.  Two  more  folds  are 
formed  over  the  first  two.  The  stomach-wall  is  stitched  to  the 
parietal  peritoneum  and  sheath  of  the  rectus  muscle  (Willy 
Me\-er).  The  Ssabanejew-Frank  operation  is  preferred  by 
many  surgeons.  Fenger's  incision  is  made  (a  cur\"ed  incision 
at  the  margin  of  the  costal  cartilages  of  the  left  side).  A  cone 
of  the  stomach  is  pulled  out  of  the  wound  and  is  passed  under 
a  bridge  of  sldn  which  has  been  prepared  for  it.  The  stomach 
is  fixed  above  the  margin  of  the  ribs  and  opened  (Figs.  217, 
218).    Van  Hacker  makes  the  gastric  fistula  through  the  left 

rectus  muscle,  and  Hahn 
between  two  of  the  rib 
cartilages  (Willy  Meyer). 
Emanuel    Senn    dexised 


Figs.  217,  iiS — Frank's  method  of  gaitrostomy  in  .;-ir>:...:::.. 


:e  escpBagUS. 


the  follo\nng  method :  a  cone  of  the  stomach  is  pulled  out 
of  the  abdominal  wound,  and  this  cone  is  puckered  by  the 
insertion  of  two  dra\\-ing-string  sutures  of  chromic  catgut 
through  the  serous  and  muscular  coats.  A  cuff  of  gastro- 
cohc  omentum  is  sutured  bv  silk  around  the  neck  of  the 


68o  MODERN  SURGERY. 

puckered  cone.  The  stomach  is  sutured  to  the  belly-wall 
with  silk,  the  sutures,  including  the  omental  cuff,  the  serous 
and  muscular  coats  of  the  stomach,  and  the  structures  of 
the  belly-wall,  except  the  skin.  The  skin  is  partially  sutured. 
The  stomach  may  be  opened  at  any  time. 

Gastro -enterostomy  (Senn's  method)  is  the  establish- 
ment of  a  permanent  fistula  between  the  stomach  and  the 
small  intestine,  in  order  to  side-track  the  pylorus.  The  stom- 
ach is  irrigated  as  before  pylorectomy.  In  the  operation  of 
gastro-enterostomy  a  median  incision  is  made  through  the 
abdominal  wall,  from  below  the  xiphoid  cartilage  to  the  um- 
bihcus.  An  opening  is  made  in  the  stomach,  in  the  direction 
of  the  long  axis  of  the  viscus,  and  its  edges  are  stitched  with 
a  continuous  catgut  suture.  The  contents  of  the  bowel  are 
forced  along  to  below  the  point  where  an  incision  is  to  be 
made ;  a  rubber  tube  is  fastened,  around  the  bowel  above 
this  point,  and  another  below  it;  an  incision  is  made  in  the 
long  axis  of  the  bowel,  and  the  margins  of  the  wound  are 
sutured  in  the  same  manner  as  the 
stomach-wound.  Bone  plates  are  in- 
troduced into  the  stomach  and  intes- 
tine, and  the  ligatures  are  tied  as  in 
intestinal  anastomosis  (page  ^'})']^. 
Catgut  rings  or  rubber  rings  may  be 
used.  Fig.  2 1 9  shows  Wolfler's  meth- 
od of  gastro-enterostomy.  Kocher's 
method  is  as  follows :  after  opening 
''^' ^'^(^ter^W5iflerr°^'°'"^  the  abdomcn,  lift  up  the  omentum, 
pull  up  a  loop  of  intestine  and  find 
the  point  where  the  jejunum  appears  from  under  the  meso- 
colon. Select  a  loop  sixteen  inches  from  the  origin  of  the 
jejunum  and  prepare  to  attach  it  to  the  stomach.  Wolfler 
showed  that  the  intestine  should  be  applied  to  the  stomach  in 
such  a  manner  that  the  direction  of  peristalsis  in  the  bowel 
must  correspond  to  the  direction  of  the  stomach-tide.  This 
can  be  accomplished  by  having  the  proximal  portion  of  gut  to 
the  left,  and  the  distal  portion  to  the  right.  The  operation  is 
to  be  so  performed  that  after  its  completion  the  stomach-con- 
tents pass  into  the  distal  portion  of  the  gut,  and  the  intesti- 
nal contents  do  not  tend  to  enter  the  stomach.  In  order  to 
accomplish  this  Kocher  hangs  the  intestine  to  the  stomach- 
wall  in  such  a  manner  that  the  proximal  portion  of  the  loop  is 
posterior  and  ascending,  and  the  distal  portion  is  anterior  and 
descending.  The  bowel  is  hung  to  the  stomach  by  a  con- 
tinuous serous  suture  of  silk,  the  ends  of  which  are  left  long. 


DISEASES  AND   INJURIES   OF  THE  ABDOMEN       68 1 

The  intestine  is  opened  by  a  curved  incision,  the  convexity 
of  which  is  downward.  The  stomach  is  opened  so  that  the 
convexity  of  the  cut  is  upward.  The  valve-Hke  portion  of 
the  bowel-wall  is  sutured  to  the  stomach  below  the  incision 
in  that  viscus.  The  two  openings  are  well  approximated 
by  sutures. 

Gastro-enterostomy  may  be  quickly  performed  by  the  use 
of  a  large-sized  Murphy  button.  Murphy  says  that  in  some 
reported  cases  the  button  has  slipped  back  into  the  stomach, 
but  this  accident  can  be  prevented  by  the  use  of  an  oblong 
button  and  by  making  the  anastomosis  on  the  posterior  stom- 
ach-wall. The  same  surgeon  advises  us  to  scarify  the  peri- 
toneum to  hasten  union,  and  says  supporting  sutures  about 
the  button  are  not  required,  except  when  considerable  ten- 
sion exists.  There  is  no  question  that  an  anastomosis  on  the 
anterior  wall,  accomplished  by  a  Murphy  button,  can  be 
speedily  performed.  Anastomosis  on  the  posterior  wall  can- 
not be  performed  speedily,  and  it  sacrifices  the  great  advan- 
tage of  the  button  operation — that  is,  speed.  In  spite  of  the 
reported  cases,  we  can  truthfully  assert  that  the  danger  of 
the  button  producing  grave  trouble  is  slight. 

Gastrogastrostotny  is  an  operation' performed  for  hour- 
glass contraction  of  the  stomach,  a  condition  which  occasion- 
ally ensues  on  the  healing  of  an  ulcer.  In  this  operation  an 
anastomosis  is  effected  between  the  pyloric  and  cardiac  ends. 
Wolfe,  Watson,  Wolfler,  and  Eiselberg  have  performed  this 
operation.  Weir  and  Foote  maintain  that  double  gastro- 
enterostomy, "  tapping  each  sac,"  is  a  preferable  procedure.^ 

Gastroplication  (Brandt's  Operation  of  Stomach- 
reefing  for  Dilated  Stomach). — Apply  sutures  in  the  ante- 
rior wall  so  as  to  form  reefs,  then  tear  throuo-h  the  crreat  omen- 
tum  and  apply  sutures  in  the  posterior  wall.  The  sutures  pass 
through  the  serous  and  muscular  coats,  and  150  to  200  are 
inserted.  This  operation  is  of  questionable  value,  and  must 
never  be  used  if  stenosis  of  the  pylorus  exists,  and  stenosis 
of  the  pylorus  is  the  most  common  cause  of  gastric  dilatation. 

Bnterectomy,  or  Resection  of  the  Intestine  with 
Anastomosis  by  Circular  i^nterorrhaphy, — After  open- 
ing the  abdomen  isolate  the  loop  of  intestine  it  is  intended  to 
resect.  Push  a  rubber  tube  through  the  mesentery  close  to 
the  bowel,  above  the  seat  of  operation,  and  pass  a  rubber  tube 
through  the  mesentery  below  the  seat  of  operation.  Empty 
this  segment  of  bowel  by  squeezing  and  stroking,  tighten  the 

'  F.  S.  Watson,  in  Boston  Med.  and  Surg.  Jour.,  April  2,  1896;  Weir  and 
Foote,  Medical  News,  April  25,  1896. 


682 


MODERN  SURGERY. 


rubber  tubes,  and  clamp  thern  to  keep  the  bowel  empty.  In- 
stead of  tubes,  strips  of  iodoform  gauze  may  be  used  to  en- 
circle the  bowel.  The  diseased  intestine  is  resected,  each  in- 
cision being  carried  through  a  healthy  segment.  The  lumen 
of  each  end  of  the  divided  gut  is  irrigated  with  salt  solution. 
The  divided  surfaces  are  approximated  by  a  double  row  of 
sutures — a  continuous  suture  for  the  mucous  membrane,  and 
Lembert's,  Dupuytren's,  or  Cushing's  suture  to  effect  inver- 
sion. Thoroughly  satisfactory  approximation  can  be  effected 
by  one  row  of  Halsted  sutures.  If  a  redundant  fold  of  mesen- 
tery is  left,  it  can  be  stitched  at  its  raw  edge.  Many  surgeons 
remove  a  V-shaped  piece  of  mesentery  and  tie  the  mesen- 
teric vessels.  The  tubes  are  removed,  and  the  wound  is 
cleansed,   closed,  and   dressed.     Fig.  220  shows  the  tubes 


Fig.  220. — Excision  of  bowel  :  first  step 
(Esmarch  and  Kowalzig). 


Fig.  221. — Excision  of  bowel  with  en- 
terorrhaphy  and  stitching  of  the  redun- 
dant mesentery  :  second  step  (Esmarch 
and  Kowalzig). 


fastened  for  excision  of  the  bowel,  and  Fig.  221  shows  enter- 
orrhaphy  with  stitching  of  the  redundant  mesentery. 

Senn  effects  invagination  by  means  of  a  ring  (Fig.  223). 

If  the  two  segments  of  bowel  are  unequal  in  size,  the  nar- 
rower part  of  the  bowel  should  be  cut  obliquely  and  the 
larger  part  should  be  cut  transversely.  To  meet  this  com- 
plication Billroth  devised  lateral  implantation.  Suppose  the 
cecum  has  been  resected  :  its  lower  end  is  closed  by  Lembert 
sutures,  an  opening  is  made  in  the  long  axis  of  the  periphery 
of  the  colon  opposite  the  mesocolon  attachment,  and  the  end 
of  the  ileum  is  sutured  into  this  incision. 

Senn  advises  the  insertion  of  an  anastomosis-ring  in  the 
ileum,  the  invagination  of  the  colon  as  the  ring  is  pulled  into 
place,  and  firm  suturing  of  the  line  of  junction.  By  Senn's 
method  the  ileiim  may  be  implanted  into  the  end  of  the  colon  or 
into  a  slit  in  the  wall  of  a  large  bowel  after  the  end  of  the  colon 
has  been  closed.    In  some  cases,  where  one  portion  of  bowel 


DISEASES  AND  INJURIES   OF   THE  ABDOMEN.       683 


is  larger  than  the  other,  lateral  anastomosis  is  the  prefer- 
able method.  For  a  full  week  after  an  intestinal  resection 
the  patient  is  fed  chiefly  by  nutrient  enemata.  During  the 
first  twenty-four  hours  nothing  is  given  by  the  stomach  but 


;l  1  ;,■..  V ''X 


x 


Fig.  222. — Resection  of  intestine  :  a,  h,  the  two  halves  of  the  button  ;  c,  the  two  portions 
clamped  together;  d,  introduction  of  the  sutures  for  holding  each  half  of  the  button  in  place. 
The  lower  figure  shows  the  completed  union  of  the  intestine  by  the  Murphy  button  ;  the  slip 
in  the  mesentery  has  been  closed  by  linear  union  (after  Zuckerkandl). 

bits  of  ice,  and  for  the  next  six  days  but  a  very  little  liquid 
food  is  allowed  to  be  swallowed. 

The  use  of  Murphy's  button  permits  of  rapid  approximation 
after  resection  (Fig.  222,  r).  This  button  closely  approximates 
the  portions  of  the  intestine  within  its  bite,  rapid  adhesion 
taking  place.  The  diaphragm  of  tissue  undergoes  pressure- 
atrophy,  and  liberates  the  button,  which  is  passed  per  anum. 
It  is  claimed  that  the  button-opening  contracts  but  slightly. 


684 


MODERN  SURGERY. 


For  end-to-end  or  side-to-side  approximation  of  the  small 
intestine  a  No.  3  button  is  used.  For  similar  operations  on. 
the  large  intestine  a  No.  4  button  is  employed  (Murphy), 
After  the  resection  one-half  of  a  button  is  inserted  into  each 
segment,  and  is  held  in  place  by  a  purse-string  suture  of  silk 
which  passes  through  all  the  coats  (Fig.  222).  The  redun- 
dant mucous  membrane  is  tucked  in  or  clipped  off,  so  that  it 
will  not  be  interposed  between  the  serous  surfaces.  The  serous 
surfaces  are  scratched  with  a  needle  and  the  two  halves  of  the 
button  are  locked  (Fig.  222).  It  is  not  necessary  to  surround 
the  margin  of  junction  with  sutures.  Murphy  says  that  liquid 
nourishment  should  be  given  as  soon  as  the  patient  has  recov- 
ered from  the  effects  of  the  ether,  and  that  the  bowels  should 
be  moved  at. an  early  period  and  frequent  evacuations  should 
be  maintained.     If  the  button  does  not  pass  in  four  weeks,. 


Fig.  223. — Senn's  modification  of  Jobert's  invagination  method;  A,  upper  end  lined 
with  ring;  .5,  invagination  sutures  in  place  ;    C,  lower  end. 

examine  the  rectum  for  it.^  The  situation  of  the  button  can 
be  ascertained  by  the  X-rays.  After  intestinal  resection 
Halsted  performs  circular  enterorrhaphy  by  means  of  his 
mattress-sutures. 

Maunsell  has  devised  a  most  ingenious  method  of  cir- 
cular enterorrhaphy.  The  two  portions  of  bowel  are  at- 
tached by  two  fixation-sutures  which  penetrate  all  the 
coats  (Fig.  224).  An  incision  one  and  one-half  inches  in 
length  is  made  through  the  wall  of  the  proximal  seg- 
ment of  gut,  about  one  inch  from  its  edge.  The  fixa- 
tion-sutures are  brought  through  this  opening,  traction  is 
made  upon  them,  the  distal  portion  of  the  bowel  is  in- 
vaginated  into  the  proximal  portion,  and  the  ends  emerge 
from  the  opening,  their  peritoneal  surfaces  being  in  contact 

1  John  B.  Murphy,  in  Med.  News  Feb.  9,  1895. 


DISEASES  AND   INJURIES   OF   THE   ABDOMEN.       685 

(Fig.  224).  Sutures  of  silk  are  passed  through  both  sides  of 
the  area  of  invagination,  the  threads  are  caught  up  in  the  cen- 
ter, cut,  and  tied  on  each  side.  The  fixation-sutures  are  cut  off 
The  invagination  is  reduced  by  traction.  The  longitudinal  cut 
is  closed  by  Lembert  sutures. 


Fig.  224. — Maunsell's  method  of  anastomosis  (after  Wiggin). 


Fig.  225. — Robson's  decalcified  bone  bobbin. 

Mayo  Robson  performs  circular  enterorrhaphy  over  a 
bobbin  of  decalcified  bone  (Fig.  225).  Allingham  uses 
a   bone   bobbin   the   shape    of  two    cones  joined  at   their 


686 


MODERN  SURGERY. 


apices.  The  bobbin  is  decalcified  except  an  area  at  the 
center  (Fig.  226).  Kocher  performs  circular  enterorrhaphy 
as  follows  :  a  fixation-suture  is  introduced  through  the  bowel 


Fig.  226. — Allingham's  decalcified  bone  bobbin. 

at  the  mesenteric  attachment  and  another  is  inserted  at  an 
opposite  point.  The  intestinal  ends  are  approximated  by 
a  continuous  silk  suture,  which  passes  through  all  of  the 


Fig.  227.— Harris's  method  of  circular  enterorrhaphy. 

coats,  but  which  includes  more  of  the  serous  than  of  the 
mucous  coat.  The  suture-line  is  overlaid  by  a  continuous 
Lembert  suture  which  includes  the  serous  and  a  portion  of 


DISEASES  AND  INJURIES   OF  THE  ABDOMEN.       ^^J 

the  muscular  coat.  Harris  removes  a  portion  of  mucous 
membrane  from  the  distal  end  by  means  of  a  curet.  Three 
needles  are  threaded  with  fine  silk.  The  first  needle  is 
pushed  through  the  bowel-wall  to  one  side  of  the  mesentery. 
The  point  of  the  needle  picks  up  a  portion  of  the  distal  end 
transversely.  The  needle  is  used  as  a  lever  to  invaginate  the 
distal  end  into  the  proximal  end.  The  same  procedure  is 
carried  out  with  the  other  needles.  When  invagination  is 
effected  the  needles  are  pulled  through  and  the  threads  are 
tied.  The  free  end  of  the  bowel  is  now  sutured  to  the  in- 
vaginated  part  by  interrupted  sutures  or  by  a  continuous 
suture  broken  once  (Fig.  227).^ 

Some  surgeons  employ  inflatable  rubber  cylinders  in 
making  an  end-to-end  anastomosis  (Halsted,  Downes,  Re- 
der).  Halsted  shows  that  the  use  of  the  inflatable  rubber 
cylinder  enables  the  surgeon  to  finish  the  operation  more 
quickly  and  to  dispense  with  clamps ;  arrests  the  vermicular 
motion  of  the  intestine;  makes  easy  the  adjustment  of  two 
pieces  of  intestine  of  unequal  size ;  and  renders  it  possible  to 
apply  stitches  rapidly,  evenly,  and  securely.^   Three  presection 


Fig.  228. — Use  of  Halsted's  inflated  rubber  cylinder  in  circular  enterorrhaphy. 


sutures  are  inserted  ;  a  portion  of  bowel  and  a  V-shaped  piece 
of  mesentery  are  resected,  the  mesenteric  incision  being  so 
made  as  to  leave  a  vessel  uncut  at  each  edge  to  supply  each 
end  of  the  divided  intestine.      The  mesenteric  vessels  are 

1  Chicago  Med.  Record,  ]3.n.,  1897.         ^  Phila.  Med.  Jour.,  Jan.  8,  1898. 


688 


MODERN  SURGERY. 


ligated  and  the  ends  of  the  bowel  are  pulled  together  by 
the  presection  stitches,  two  of  which  are  tied.  The  col- 
lapsed rubber  cylinder  is  pushed  into  the  bowel  by  means  of 
forceps  and  is  inflated  with  a  syringe  (Fig.  228).  Twelve 
mattress  sutures  are  inserted  and  the  bag  is  collapsed  and 
withdrawn  and  the  sutures  are  tied,  the  stitch  a  being  tied 
first  (Fig.  228).     The  slit  in  the  mesentery  is  sewed  in  such 


Fig.  229. — Suture  of  the  mesentery  after  circular  enterorrhaphy  (Halsted). 


a  way  that  the  mesenteric  vessels  which  nourish  the  bowel 
are  not  interfered  with  (Fig.  229). 

I<ateral  Intestinal  Anastomosis.  —  Approximation 
may  be  effected  by  other  methods  than  by  end-to-end  junc- 
tion or  by  implantation.  Lateral  anastomosis  may  be  prac- 
tised after  intestinal  resection  or  may  be  done  with  prelimi- 
nary resection  for  the  purpose  of  short-circuiting  the  fecal 
current  to  avoid  an  obstruction. 

Operation  with  Rings. — In  this  operation  a  portion  of 


Fig.  230. — Sarin's  entero-anastomosis :  a,  Senn's  bone  plate;  b,  intestinal  anastomosis  ; 
C,  operation  complete. 

bowel  above  the  obstruction  and  a  loop  below  the  obstruc- 
tion  are   brought   into    the  wound.      These   segments    are 


DISEASES  AND   INJURIES   OF  THE  ABDOMEN.       689 


emptied,  and  are  kept  empty  by  fastening  around  them 
rubber  tubes  or  iodoform  strips.  Two  tubes  are  needed  for 
each  loop  of  bowel.  Pack  in 
gauze  pads.  Make  an  in- 
cision in  one  loop,  in  the 
long  axis  of  the  bowel,  on 
the  surface  away  from  the 
mesentery ;  permit  the  con- 
tents to  escape  externally ; 
irrigate  this  segment  with 
saline  solution ;  and  introduce 
the  bone  plate  of  Senn  (Fig. 
230,  a)  or  Abbe's  catgut  ring. 
Calyx-eyed  needles  are  used, 
and  the  threads  of  the  ring 
are  carried  through  the  coats 
of  the  bowel  and  are  gath- 
ered together  in  the  bite  of 
a  pair  of  forceps.  The  other 
loop  of  intestine  is  treated 
in  a  similar  manner.  The 
intestines     are    so    brought 

together  that  the  two  wounds  are  opposite  each  other,  the 
posterior  sutures  being  tied  first,  the  upper  next,  then  the 


Fig.  231. — Method  of  passing  the  silk  sutures 
in  inserting  the  rings  of  Abbe. 


Wm. 


Fig.  232. — Showing  relative  size  of  incision  and  method  of  introducing  sutures  in  lateral 
appro.\imation  with  Murphy's  button. 

lower,  and  finally  the  anterior  threads.     The  ends   of  the 
threads  are  cut  off  and  the  entire  anastomosis  is  surrounded 
by  a  layer  of  Lembert  sutures  or  is  encircled  by  Cushing's 
.44 


690 


MODERN  SURGERY. 


'suture.  Fig.  230,  b,  shows  an  intestinal  anastomosis  partly 
finished,  and  Fig.  230,  c,  shows  an  anastomosis  complete. 
Fig.  231  shows  the  passing  of  the  sutures  when  the  catgut 
rings  of  Abbe  are  employed.  After  an  intestinal  resection, 
each  end  can  be  closed  and  anastomosis  effected  as  described 
above.  Lateral  anastomosis  can  be  accomplished  with  a 
Murphy  button,  the  intestine  being  prepared  for  the  button 
as  is  shown  in  Fig.  232. 

Abbe's  method  of  anastomosis  without  mechanical  aid 
is  as  follows :  after  resecting  the  bowel  and  mesentery 
and  closing  the  ends  of  the  bowel  he  places  the  extrem- 
ities side  by  side  and  appHes  two  rows  of  a  Dupuytren 
suture,  one-quarter  of  an  inch  apart.  These  rows  of 
sutures  are  an  inch  longer  than  the  slit  in  the  bowel 
will   be  (Fig.    233),   the   thread    at   the    end    of  each    row 


Fig.  233. — Suturing  intestines  in  apposition  before  incision  (Abbe). 

being  left  long.  An  incision  is  made  in  the  bowel,  one- 
quarter  of  an  inch  from  the  sutures,  both  rows  of  threads 
being  on  the  same  side  of  the  cut.  This  incision  is  four 
inches  long.     The  other  portion  of  bowel  is  then  incised  in 


Fig.  234. — Showing  the  four-inch  incision  and  sewing  of  the  edges  (Abbe). 

the  same  way.  The  adjacent  cut-edges  are  united  by  a 
whip-stitch  which  goes  through  all  the  coats,  and  the  free 
cut-edges  are  stitched  in  the  same  manner  (Fig.  234).     The 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       69 1 

surgeon  now  utilizes  the  long  threads  of  the  first  sutures, 
and  brings  the  serous  surfaces  of  the  opposite  sides  together 
by  means  of  Dupuytren's  suture.  Halsted  performs  anasto- 
mosis as  follows  :  he  places  the  two  portions  of  bowel  with 
their  mesenteric  borders  in  contact.     Six  quilted  sutures  of 


V^v^Amuvuw; 


Fig.  235. — Halsted's  operation  for  lateral  anastomosis,  showing  four  steps  of  same  (Jessett, 

from  Halsted). 


silk  are  introduced,  tied,  and  cut  off  (Fig.  235,  a).  At  each 
end  of  this  row  of  sutures  two  quilted  sutures  are  intro- 
duced, tied,  and  cut  (Fig.  235,  /;).  A  number  of  quilted  sutures 
are  introduced,  as  is  shown  in  Fig.  235,  c.  The  intestinal 
openings  are  made  with  scissors,  and  the  sutures  last  intro- 
duced are  tied  and  cut  off  (Fig.  235,  d). 

J.  Shelton  Horsley  has  suggested  an  ingenious  method 
of  intestinal  anastomosis  which  secures  for  the  sutured 
portion  a  greater  diameter  than  that  normal  to  the  intes- 
tine.^ After  resection  of  the  intestine  and  a  V-shaped  piece 
of  mesentery,  the  ends  of  the  bowel  are  placed  side  by 
side,  the  openings  being  in  the  same  direction,  and  are 
clamped   in   place   (Fig.    236).       The    first    stitch    approxi- 

1  New  York  Polyclinic. 


692 


MODERN  SURGERY. 


mates  the  two  limbs  of  the  bowel  near  the  mesenteric  at- 
tachment, is  carried  obliquely  for  about  two  inches  to  the 


Fig.  236. — Represents  the  ends  of  the  intestine  in  position  and  grasped  by  the  artery-forceps. 
The  first  row  of  sutures  has  been  partially  applied,  the  septum  partly  cut  away,  and  the 
second  row  of  overhand  sutures  begun,  a,  b,  are  the  two  ends  of  the  intestine  ;  c,  c,  the  first 
row  of  sutures  (Gushing)  ;  d,  the  second  row  of  sutures  (overhand)  ;  e,  the  septum;  _/"and^, 
the  mesentery  (J.  Shelton  Horsley). 

border  opposite  the  mesenteric  attachment  and  continued 
over  the  other  side  (Fig.  236).  The  septum  is  cut  away,  a 
margin  being  left  one-third  of  an  inch  wide.  The  edge  of 
the  shelf  made  by  cutting  the  septum  is  sutured.     When  the 


Fig.  237. — Operation  nearly  completed.  The  septum  has  been  cut  away,  and  the  row  of 
overhand  sutures  has  been  brought  almost  to  its  point  of  commencement.  The  cut  also  shows 
the  first  row  of  sutures  (Gushing)  as  it  should  be  continued  after  the  overhand  sutures  are 
finished  (J.  Shelton  Horsley). 

suture   reaches  the  end  of  the  shelf  it  is   continued  by  in- 
vaginating  the  rest  of  the  resected  ends  (Fig.  237). 


DISEASES  AND   INJURIES   OF   THE   ABDOMEN.       693 

Bodine's  method  of  intestinal  anastomosis  is  referred,  to 
at  page  695. 

Consideration  of  Methods  of  Intestinal  Approxima- 
tion.— The  best  method  of  uniting  a  divided  intestine  is  a 
matter  of  dispute.  The  Murphy  button  can  be  apphed  with 
great  rapidity,  and  rapid  operation  is  of  immense  importance 
in  intestinal  work.  The  opening  left  by  the  Murphy  button  is 
small  (too  small  some  surgeons  think),  but  it  does  not  strongly 
tend  in  most  instances  to  contract  because  the  tissue-dia- 
phragm is  separated  by  tissue-atrophy  and  not  by  inflamma- 
tory gangrene.  Occasionally  the  opening  made  by  the  but- 
ton contracts  and  gives  trouble ;  occasionally  the  lumen  of 
the  button  blocks  with  feces ;  occasionally  the  button  is 
retained,  this  later  complication  being  especially  frequent 
after  gastro-enterostomy.  If  the  button  is  used,  liquid  food 
should  be  given  soon  after  the  effect  of  the  anesthetic  has 
passed  off,  and  movement  of  the  bowels  should  be  obtained 
at  an  early  period  after  operation  and  frequent  evacuations 
should  be  maintained.  The  button  gives  better  results  in 
end-to-end  approximation  than  in  lateral  anastomosis.  The 
decalcified  bone  plates  of  Senn,  the  catgut  rings  of  Abbe, 
the  catgut  strands  inside  of  rubber  tubing  of  Brokaw, 
Chaput's  button,  Allingham's  bone  bobbin,  Robson's  bone 
bobbin,  Clark's  bobbin,  Miller's  bone  buttons,  buttons  of 
leather,  potato,  and  carrot,  all  hav^e  their  adherents.  Of 
mechanical  appliances  the  best  are  the  metal  button,  the 
bone  ring,  and  the  inflatable  rubber  cylinder.  Of  recent 
years  many  surgeons  have  abandoned  all  mechanical  aids, 
and  hav^e  returned  to  closure  without  any  mechanical  de- 
vice whatever.  The  ideal  operation  is  without  these  con- 
trivances. But  such  devices  are  time-savers,  and  to  lessen 
the  time  of  operation  will  often  save  life.  What  method  to 
follow  must  be  determined  in  each  particular  case  by  a  study 
of  the  necessities  of  the  case.  Nevertheless  it  may  be  pos- 
sible to  formulate  a  few  general  rules.  If  the  condition  of 
the  patient  is  excellent  and  the  bowel  is  in  a  fairly  healthy  con- 
dition well  above  and  well  below  the  seat  of  trouble,  end-to- 
end  approximation  should  be  performed  by  circular  enteror- 
rhaphy,  and  this  can  be  greatly  facilitated  by  the  use  of  an 
inflatable  rubber  cylinder.  If  the  condition  of  the  patient  is 
such  as  to  make  haste  necessary',  use  a  Murphy  button.  If 
the  bowel  below  the  seat  of  trouble  is  much  contracted, 
do  not  use  a  Murphy  button,  but  use  Senn's  bone  plate,  or 
Robson's  bobbin,  or,  better  still,  do  circular  enterorrhaphy 
with    the    aid    of  inflatable    cylinders.       If  the    surgeon   is 


694  MODERN  SURGERY. 

obliged  to  join  a  very  much  distended  bowel  to  a  very  much 
contracted  bowel,  perform  end-to-side  approximation  (implan- 
tation) with  the  bone  plate  of  Senn,  by  simple  suturing,  or 
else  effect  side-to-side  junction  by  the  method  of  Abbe.^ 

Operation  for  Intussusception. — If  hydrostatic  press- 
ure or  air  distention  fails  to  relieve  the  condition,  operation 
should  be  performed.  The  abdomen  is  opened,  and  the 
surgeon  endeavors  by  manipulation  to  reduce  the  intussus- 
ception by  pushing  it  back,  not  by  pulhng  it  out.  If 
the  intussusception  is  gangrenous,  perform  intestinal  resec- 
tion and  circular  enterorrhaphy.  The  same  rule  main- 
tains when  malignant  disease  of  the  gut  exists  (D'Arcy 
Power).  It  is  inadvisable  to  make  an  artificial  anus.  Maun- 
sell's  operation  is  suited  to  cases  of  irreducible  intussuscep- 
tion. It  is  performed  as  follows :  a  longitudinal  incision  is 
made  in  the  intussuscipiens.  The  intussusception  is  gently 
pulled  upon  and  is  caused  to  protrude  from  this  opening. 
Two  straight  needles  threaded  with  horse-hair  are  passed  so 
as  to  transfix  the  base,  and  one-fourth  of  an  inch  above  the 
needles  the  intussusception  is  cut  off.  The  needles  are 
carried  completely  through,  the  sutures  are  hooked  up  in 
the  middle  and  cut,  and  the  two  ends  are  tied  on  each  side. 
These  sutures  unite  the  intussusception  to  the  intussuscipiens. 
The  two  surfaces  are  now  carefully  approximated  by  sutures. 
The  sutures  are  cut.  The  stump  is  replaced.  The  longi- 
tudinal incision  is  closed  with  Lembert  sutures.^ 

Senn's  Operation  for  Fecal  Fistula. — Suture  the 
opening  transversely  with  Czerny  sutures  of  silk  in  order 
to  prevent  infection.  Cleanse  the  abdomen  thoroughly. 
Open  the  abdomen  and  separate  the  edges  of  the  bowel 
from  the  parietes.  Attach  the  intestine  to  diminish  the 
flexion  which  causes  the  spur.  Apply  Lembert  sutures 
over  the  Czerny  sutures.  Another  method  is  to  open  the 
abdomen  above  the  fistula,  insert  the  fingers,  cut  out  the 
skin  and  tissues  around  the  fistula  in  an  elliptical  course, 
leaving  them  attached  to  the  bowel,  draw  the  bowel  from 
the  abdomen,  pack  gauze  around,  remove  the  tissues  ad- 
herent to  it,  and  suture  the  fistula  transversely  (Hearn). 

Hnterostomy  is  the  making  of  an  artificial  anus.  If  per- 
formed in  the  large  bowel,  it  is  called  colostomy. 

Inguinal  Colostomy. — Maydl's  Operation. — In  this 
operation  a  vertical  or  oblique  incision  four  inches  long  is  made 

^  See  the  discussion  of  this  subject  by  the  late  Greig  Smith  in  his  Abdominal 
Surge7-y. 

^  T.  Pickering  Pick,  Quarterly  Med.  Jour.,  Jan.,  1897. 


DISEASES  AND    INJURIES   OF   THE   ABDOMEN.       695 

over  the  portion  of  colon  to  be  incised.  In  all  cases  where  it 
is  possible,  do  a  left  inguinal  colostomy.  The  colon  usually 
bulges  into  the  wound,  but  if  it  does  not  it  may  easily  be  found 
by  following  with  the  finger  the  parietal  peritoneum  outward, 
backward,  and  inward,  the  first  obstruction  it  encounters 
being  the  mesocolon.  Draw  the  colon  out  of  the  wound 
until  its  mesenteric  attachment  is  level  with  the  abdominal 
incision.  Push  a  glass  bar  through  a  slit  in  the  mesocolon 
near  the  bowel,  and  wrap  the  ends  of  the  bar  with  iodoform 
gauze  to  prevent  slipping.  Instead  of  the  bar  a  piece  of 
gauze  can  be  employed,  or  a  bridge  of  skin  can  be  made 
under  the  bowel  by  suturing  the  two  skin  edges.  The  two 
parts  of  the  flexure  are  stitched  together  by  sutures  which 
penetrate  to  and  catch  the,  submucous  coat  (Fig.  238).    If  the 


Fig.  238. — Inguinal  colostomy  (after  Zuckerkandl). 

colon  has  to  be  opened  during  the  operation,  stitch  the  serous 
coat  of  the  bowel  to  the  parietal  peritoneum  before  opening. 
Whenever  possible,  wait  from  twelve  to  twenty-four  hours 
before  opening.  The  colon  is  opened  by  the  cautery  or  by 
scissors.  If  the  artificial  anus  is  to  be  permanent,  make  a 
transverse  incision  through  the  bowel.  Some  surgeons  cut 
one-fourth  way  through  the  colon  when  it  is  first  opened, 
and  entirely  across  at  a  later  period.  If  the  artificial  anus 
is  to  be  temporary,  the  incision  is  longitudinal.  This  opera- 
tion has  great  advantages :  it  is  quick,  certain,  reasonably 
safe,  and  satisfactorily  prevents  fecal  accumulation  below  the 
opening. 

Bodine  has  devised  a  method  of  colostomy  which  permits 
of  a  future  restoration  of  the  fecal  current  by  an  easily  per- 
formed anastomosis.  This  surgeon  maintains  that  the  spur 
after  colostomy  should  reach  to  and  remain  at  the  level  of 


696 


MODERN  SURGE R  V. 


Fig.  239. — Bodine's  method  of  colostomy,  showing  one  side  of  the  loop  after  it  has  been 
sutured,  passed  back  into  the  cavity  and  stitched  into  the  abdominal  wound.  The  lesion  is 
left  protruding,  and  the  dotted  line  indicates  where  the  protrusion  is  to  be  clipped  off. 

the  skin,  a  condition  impossible  of  attainment  by  hanging 
the  bowel  over  a  rod  or  piece  of  gauze,  because  a  spur  thus 


Fig.  240. — Bodine's  method  of  colostomy,  showing  the  septum  to  be  divided  in  restoring 
the  fecal  current;  Grant's  clamp  in  position  for  the  division.  (In  permanent  colostomy  this 
septum  remains  as  a  rigid  and  effective  spur.) 

formed  is  not  thick  and  rigid  and  is  inevitably  dragged  below 
the  skin-level,  and  when  this  dragging  has  taken  place  some 


DISEASES  AND   INJURIES   OF  THE  ABDOMEN.       697 

fecal  matter  will  pass  into  the  bowel  below  the  artificial  anus. 
Bodine  opens  the  abdomen,  sutures  the  parietal  peritoneum 
to  the  skin,  seeks  for  the  lesion,  and  draws  it  with  six  inches 
of  healthy  bowel  out  of  the  incision.  He  lays  the  limbs  of 
the  loop  side  by  side.  He  inserts  a  silk  stitch,  beginning  at 
the  point  where  exsection  is  to  be  made,  and  for  six  inches 
unites  the  two  segments  close  to  their  mesenteric  borders. 
The  loop  is  dropped  into  the  abdomen  until  the  beginning 
of  the  suture  is  on  a  level  with  the  skin,  and  at  this  point  it 
is  fastened  to  the  abdominal  wound  with  a  continuous  catgut 
suture.  The  protruding  lesion  is  cut  off  along  the  dotted 
line  (Fig.  239).  The  artificial  anus  is  thus  established. 
When  it  is  desired  to  close  the  artificial  anus,  divide  the  sep- 
tum with  scissors  or  a  Grant  clamp,  and  close  the  abdominal 
wound  (Fig.  240).^ 

Lumbar  colostomy  is  a  most  unsatisfactory  operation, 
which  does  not  completely  intercept  the  fecal  current,  and 
which  leaves  the  patient  in  a  condition  of  wretched  dis- 
comfort.    It  is  rarely  performed  at  the  present  day. 

We  should  not  make  an  artificial  anus  in  the  small  bow^el 
if  it  is  possible  to  avoid  doing  so.  One  can  be  made  with 
comparative  rapidity  near  the  ileocecal  valve,  but  the  higher 
it  is  made  the  more  likely  is  the  patient  to  perish  because  of 
lack  of  nourishment. 

Cholecystotomy  is  the  operation  of  opening  the  gall- 
bladder in  order  to  remove  gall-stones  or  secure  drainage. 
The  patient  is  placed  recumbent  with  a  sand-pillow  under  the 
back.  A  vertical  incision  is  made  in  the  right  linea  semiluna- 
ris. The  peritoneum  is  opened.  If  the  gall-bladder  is  dis- 
tended, it  is  surrounded  with  pads  and  aspirated,  and  is  then 
opened.  Gall-stones  are  removed  by  forceps,  the  scoop,  or 
irrigation.  The  gall-ducts  are  examined  by  the  fingers  exter- 
nal to  them.  If  a  stone  is  wedged  in  the  duct,  try  to  manipu- 
late it  back  into  the  gall-bladder.  If  this  fails,  introduce  an 
instrument  from  the  gall-bladder  and  break  up  the  stone  ;  if 
this  fails,  open  the  duct,  remove  the  stone,  and  close  the  in- 
cision in  the  duct  (Mayo  Robson).  Pass  a  rubber  tube  which 
has  no  side  perforations  into  the  gall-bladder,  and  suture  the 
gall-bladder  to  the  abdominal  aponeurosis  (Mayo  Robson). 
The  drainage-tube  can  usually  be  dispensed  with  in  one  week. 

Cholecystenterostomy  consists  in  making  an  anasto- 
mosis between  the  gall-bladder  and  intestine,  preferably  the 
duodenum.  It  is  employed  in  cases  of  irremovable  obstruc- 
tion of  the  cystic  or  common  duct.     It  can  be  done  most 

1  N.   V.  Polyclinic,  Feb.  15,  1S97. 


698 


MODERN  SURGERY. 


rapidly  and  successfully  by  means  of  a  small  Murphy  button. 
Before  the  gall-bladder  is  incised  it  is  aspirated.     The  oper- 


FiG.  241. — Showing  method  of  holding  parts  while  approximating  a  Murphy  button  in 
cholecystenterostomy. 


ation  is  shown  in  Fig.  241,  and  is  similar  in  performance  to 
intestinal  anastomosis. 

Splenectomy. — This  operation  is  performed  for  wounds 
and  rupture  of  the  .spleen,  cysts,  floating  spleen,  and  non- 
leukemic  splenic  hypertrophy.  It  should  not  be  performed 
if  leukemia  exists.  The  incision  is  from  the  anterior  superior 
spine  of  the  ilium  to  the  ribs  (Bryant).  The  peritoneum  is 
opened.  Adhesions  are  divided  between  ligatures.  If  the 
spleen  is  adherent  to  the  pancreas,  it  may  be  necessary  to  re- 
move a  fragment  of  the  last-named  organ  (Esmarch).  Ligate 
the  suspensory  ligament  and  cut  it.  Bring  the  spleen  well 
out  of  the  wound.  Surround  it  with  gauze  pads.  Transfix 
the  pedicle  with  stout  silk.  Tie  it  firmly,  leaving  the  ends 
long  for  a  time,  and  cut  through  the  pedicle  beyond  the 
ligature.  Ligate  the  vessels  separately  Avith  catgut.  Cut 
off  the  long  ends  of  the  silk  ligature  and  drop  the  pedicle 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       699 

back,  unless  apprehensive  of  bleeding,  when  it  may  be  fast- 
ened to  the  surface.  The  wound  is  closed  without  drain- 
age. 

Abdominal  Hernia  or  Rupture. — This  condition  is  the 
protrusion  of  a  viscus  or  part  of  a  viscus  from  the  abdominal 
cavity.  MacCormac  says  the  term  implies  that  the  pro- 
truded viscus  is  covered  with  integument ;  hence  a  protrusion 
of  viscera  through  a  wound  does  not  constitute  a  hernia.  A 
hernia  has  three  parts — the  sac,  the  sac-contents,  and  the 
sac-coverings.  The  sac  is  formed  of  peritoneum.  A  con- 
genital sac  is  due  to  developmental  defect,  and  is  found 
only  in  the  inguinal  or  umbilical  region.  An  acquired  sac 
is  due  to  intra-abdominal  pressure  bulging  the  peritoneal 
covering  of  the  internal  abdominal  ring  and  converting  it 
into  a  pouch.  The  sac  comprises  a  body,  a  neck,  and  a 
mouth.  A  sac  once  formed  is  almost  certain  to  persist, 
because  it  adheres  by  its  outer  surface  to  surrounding  parts, 
and  hence  the  sac  of  a  hernia  is  irreducible  even  when  the 
contents  are  reducible.  The  neck  of  the  sac  is  due  to  the 
constriction  through  which  the  sac  passes ;  it  becomes  fur- 
rowed and  folded,  and  the  adhesion  of  these  folds  causes  thick- 
ening and  rigidity.  Hernia  of  the  bladder  or  of  the  cecum 
has  no  sac,  or  but  a  partial  sac.  The  contents  of  the  sac  de- 
pend chiefly  on  the  situation,  a  portion  of  the  ileum  being  the 
usual  contents.  The  colon,  the  stomach,  the  great  omentum, 
the  bladder,  and  other  structures  may  enter  the  hernial  sac. 
An  cntcrocclc  contains  only  intestine  ;  an  epiploccle  contains 
only  omentum ;  an  entero-epiplocele  contains  both  omentum 
and  intestine ;  a  cystocclc  contains  a  portion  of  the  bladder. 
The  coverings  of  tJic  sac,  which  vary  with  its  situation,  will 
be  set  forth  during  the  consideration  of  special  hernia.  In 
old  herniae  the  layers  are  never  distinct,  fat  and  muscle  waste, 
tissues  adhere,  and  the  skin  stretches  and  atrophies.  The 
sac  of  a  hernia  occasionally  becomes  tubercular.  This 
condition  arises  in  old  herniae.  It  may  either  remain  local 
in  the  hernial  sac  or  spread  to  the  general  peritoneum. 
Renault  tells  us  that  tuberculosis  of  a  hernia  is  made  mani- 
fest by  increase  in  size,  pain  on  pressure,  and  loss  of  body 
weight. 

Causes  of  Hernia. — The  male  sex  is  most  liable  to  hernia. 
It  occurs  at  all  periods  of  life,  and  hereditary  predisposition 
sometimes  seems  to  exist.  Excessive  length  of  the  mesen- 
tery has  been  assigned  as  a  cause.  Any  laborious  occupa- 
tion predisposes  to  rupture.  Any  condition  which  weakens 
the  abdominal  wall  predisposes  (muscular  relaxation  from 


yOO  MODERN  SURGERY. 

ill-health,  relaxation  of  abdominal  walls  following  the  termi- 
nation of  pregnancy,  the  removal  of  a  large  tumor,  or 
tapping  for  ascites,  and  wounds  or  abscesses  of  the  ab- 
dominal wall).  The  exciting  cause  is  muscular  effort  (strain- 
ing at  stool,  coughing,  lifting  weights,  jumping,  straining  to 
make  water,  and  the  sexual  act).  All  congenital  herniae  are 
due  to  structural  defects.  Hernia  is  divided  clinically  into 
reducible,  irreducible,  incarcerated,  inflamed,  and  strangu- 
lated. 

Reducible  Hernia. — In  this  form  of  hernia  the  contents 
of  the  sac  can  be  reduced  into  the  abdominal  cavity.  At  a 
known  hernial  opening  the  patient  has  a  smooth  enlargement 
(narrower  above  than  below),  which  began  to  grow  from 
above  and  extended  downward.  A  distinct  neck  can  often 
be  felt.  In  enterocele,  straining,  lifting,  or  standing  enlarges 
the  mass  ;  the  tumor  becomes  smaller  and  may  disappear  on 
lying  down  ;  cough  causes  impulse  or  succussion  ;  the  tumor 
is  elastic,  and  on  reduction  the  mass  suddenly  disappears 
and  there  is  a  gurgling  sound.  In  epiplocele  the  mass  is 
often  irregular  and  compressible,  and  feels  boggy  rather  than 
elastic  ;  muscular  effort  does  not  have  much  influence  in  en- 
larging it ;  impulse  on  coughing  is  slight ;  percussion  gives 
a  dull  note,  and  reduction  is  accomplished  gradually  and 
produces  no  gurgling  sound.  In  entero-epiplocele  some  parts 
of  the  tumor  are  smooth,  elastic,  and  tympanitic,  others  are 
dull  on  percussion,  irregular,  and  flabby;  but  the  diagnosis 
of  this  especial  form  is  uncertain.  The  victims  of  reducible 
hernia  complain  of  some  pain  on  exertion,  of  dyspepsia,  and 
often  of  constipation. 

When  a  hernia  is  beginning  to  form  a  patient  complains 
of  muscular  pain  in  the  lower  abdomen,  and  this  condition 
may  exist  for  weeks  before  it  is  recognized  that  a  hernia  is 
present.  An  inguinal  hernia  should  be  recognized  before  it 
protrudes  from  the  external  ring.  The  tip  of  the  finger  is 
inserted  in  the  ring  and  the  patient  is  asked  to  cough.  If 
a  hernia  has  entered  the  canal,  succussion  will  be  detected 
on  coughing.  In  a  healthy  man  the  external  ring  should 
admit  the  tip  of  the  little  finger,  but  not  the  end  of  the  index 
finger.  If  the  end  of  the  index  finger  can  be  made  to  enter 
the  ring,  that  aperture  is  dilated,  and  even  if  there  is  no  hernia 
in  the  canal,  in  future  a  hernia  will  exist.  In  a  man,  if  the 
surgeon  desires  to  examine  the  ring,  he  inverts  the  skin  of 
the  scrotum  over  the  finger  and  carries  the  finger  to  or  in 
the  ring. 

TreatmeTtt  of  Reducible  Hernia. — Palliative  Treatment. — 


DISEASES  AND   INJURIES   OF  THE  ABDOMEN.       70I 

Prevent  constipation,  forbid  sudden  strains  and  violent  exer- 
cise, and  order  a  truss.  The  continued  employment  of  a 
truss,  especially  in  young  persons,  may  bring  about  a  cure. 
The  day  truss  should  be  applied  before  rising  in  the  morn- 
ing and  be  removed  after  lying  down  at  night,  when  a  light 
truss  should  be  substituted.  A  special  truss  is  applied  for 
bathing.  In  very  fat  people  there  is  always  trouble  in 
adjusting  a  truss.  A  femoral  hernia  is  more  difficult  to  keep 
reduced  than  an  inguinal  hernia.  In  those  cases  in  which 
the  gut  is  replaceable,  but  a  portion  of  omentum  is  irre- 
ducible, it  is  difficult  to  maintain  reduction  with  a  truss. 
In  an  oblique  inguinal  hernia  the  pad  of  the  truss  fits  over 
the  internal  abdominal  ring ;  in  a  direct  inguinal  hernia, 
over  the  external  abdominal  ring ;  in  a  femoral  hernia,  over 
the  femoral  ring  at  the  level  of  Gimbernat's  ligament. 
MacCormac's  rule  to  measure  for  a  truss  is  as  follows :  in 
either  inguinal  or  femoral  hernia  start  the  tape  from  the 
lower  part  of  the  hernial  opening,  carry  it  up  to  the  anterior 
superior  iliac  spine  of  the  same  side,  then  take  it  around  the 
body,  one  inch  below  the  crest  of  the  ilium,  to  the  other 
anterior  superior  iliac  spine,  and  then  to  the  upper  part 
of  the  hernial  opening.'  A  well-fitting  truss  will  keep  the 
hernia  up  even  when  the  patient  sits  in  a  position  to  relax 
the  abdominal  walls  and  coughs  and  strains.  A  truss  is 
always  uncomfortable  at  first,  but  a  person  soon  grows  used 
to  it.  It  should  be  kept  scrupulously  clean,  and  it  is  well 
to  dust  borated  talc  powder  upon  the  skin  under  the  pad  at 
least  once  a  day.  A  truss  which  does  not  keep  the  hernia  up 
or  which  causes  pain  does  harm.  Too  strong  a  spring  tends 
to  enlarge  the  hernial  orifice,  and  thus  aggravates  the  case. 
Bryant  insists  that  even  after  an  apparent  cure  with  a  truss 
the  instrument  must  be  worn  for  a  long  time. 

Radical  treatment  seeks  to  permanently  cure  by  plugging 
the  mouth  of  the  sac  or  by  obliterating  the  canal  of  descent. 
Radical  operations  should  be  performed  when  a  strangulated 
hernia  is  operated  upon,  in  ordinary  cases  of  reducible  hernia 
in  which  a  truss  is  very  painful  or  does  not  keep  the  bowel 
up,  in  most  cases  of  irreducible  hernia,  and  in  any  case 
which  has  occasional  attacks  of  obstruction.  It  used  to  be 
believed  that  a  cure  would  fail  if  the  subject  was  under  three 
years  of  age,  but  Coley  and  others  have  proved  that  it  is  a 
very  successful  operation  in  children. 

Maccwen's  Operation  for  Liginital  Hernia. — The  instru- 
ments required  in  this  operation  are  scalpels,  a  blunt,  straight 

1  Treves's  Manual  of  Surgery,  "  Hernia." 


702 


MODERN  SURGERY. 


bistoury,   a    dry    dissector,  a    grooved    director,  scissors,   a 
hernia-director,  hernia-needles  (Fig.  242),  dissecting-forceps, 

toothed  forceps,  hemostatic  for- 
ceps, an  aneurysm-needle,  blunt 
hooks,  half-curved  needles,  nee- 
dle-holder, and  chromicized  cat- 
gut sutures.  The  patient  lies 
recumbent,  the  thigh  being  ab- 
ducted and  partly  flexed  and  rest- 
ing on  a  pillow  beneath  the  knee. 
The  bowel  is  reduced,  and  an 
incision  three  inches  long  is  made  in  the  direction  of  the 
inguinal  canal,  the  center  of  the  incision  corresponding  to 
the  external  ring.  The  sac  is  freed  from  its  attachments 
below  and  is  lifted  up.     The  surgeon  introduces  a  finger  into 


Fig.  242. — A,  hernia-needles  ; 
hinged  hernia-director. 


Fig.  243. — Macewen's  operation  for  radical  cure  of  inguinal  hernia  :  A,  stripping  of 
the  sac  ;  e,  purse-string  suture  ;  c,  fastening  the  purse-string  suture  ;  D,  passing,  and  E,  tying, 
the  sutures  for  the  internal  ring. 


the  inguinal  canal  and  separates  the  sac  from  the  cord  and 
from  the  walls  of  the  canal,  and  then  carries  the  finger  through 
the  internal  ring  and  separates  the  peritoneum  for  one  inch 


DISEASES  AND   IXJURIES   OF  THE   ABDOMEN.       703 

about  the  periphery'  of  this  aperture  (Fig.  243,  a).  A  chromi- 
cized  catgut  stitch  is  fastened  to  the  lowest  portion  of  the  sac, 
and  is  passed  through  the  sac  several  times,  so  that  pulling  on 
the  stitch  will  purse  the  sac  (Fig.  243,  b).  The  free  end  of 
this  stitch  is  carried  through  the  internal  ring  into  the  belly, 
and  is  pushed  out  through  the  abdominal  muscles  one  inch 
above  the  internal  ring,  the  skin  being  pushed  aside  so  as  to 
escape  perforation  by  the  needle.  The  thread  is  tightened  so 
as  to  fold  up  the  sac  and  pull  it  into  the  belly.  This  plugs 
the  ring  (Fig.  243,  c).  The  thread  is  handed  to  an  assistant 
to  keep  tight  until  the  sutures  are  introduced  into  the  ring, 
when  the  sac  is  permanently  anchored  by  taking  several 
stitches  in  the  external  oblique  muscle.  A  strong  catgut 
suture  is  passed  with  a  Macewen  needle  through  the  con- 
joined tendon  from  below  upward,  the  ends  of  this  suture 
being  carried  through  Poupart's  ligament  and  the  outer 
borders  of  the  internal  ring  from  within  outward.  This 
suture  is  tightened  and  closes  the  internal  ring.  The  ex- 
ternal   ring    is    sutured    and    the    skin   is   stitched   together 

(Fig.  243,  e).  

In  congenital  hernia  the  sac  is  divided  in  its  middle  and  the 
lower  part  is  closed  by  stitches  of  chromic  catgut,  forming  a 
tunica  vaginalis.  The  upper  part  of  the 
sac  is  slit  posteriorly  to  permit  the  escape 
of  the  cord,  and  is  closed  by  stitches  of 
chromic  catgut.  The  operation  is  finished 
as  in  the  acquired  form  (Fig.  244).  After 
this  operation  the  patient  should  stay  in 
bed  for  about  four  weeks,  and  must  not 
work  for  eight  or  nine  weeks.  Workmen 
after  this  operation  should  always  wear 
a  pad  and  a  spica  bandage.  Children 
require  no  pad.  Never  apply  a  truss, 
as    strong    pressure    will    atrophy    the         Fig.  244— Macewen's 

r-  f'    (^       <~o  operation   for    the   radical 

curative    scar.  cure  of  congenital  hernia. 

Bassini's  Operation  for  Inguinal  Her- 
nia.— This  operation  removes  the  spermatic  cord  from  the 
old  canal  and  places  it  in  a  new  canal,  and  this  new  canal  is 
oblique.  The  instruments  employed  are  the  same  as  for 
Macewen's  operation,  excepting  the  special  needles,  which 
are  not  needed.  Hagedorn  needles  are  employed  to  insert 
the  stitches.  The  suture-material  is  kangaroo-tendon  or 
chromicized  catgut.  Silk  or  silver  wire  is  apt  to  make 
trouble — it  may  be  long  after  the  operation.  The  posi- 
tion is  the  same  as  in  Macewen's  operation.     An  incision  is 


704 


MODERN  SURGERY. 


Fig.  245,  A-c. — Bassini's  operation  for  the 
cure  of  inguinal  hernia. 


made  from  the  external  ring  to  a  point  external  to  the  inter- 
nal ring.     The  sac  is  exposed  and  twisted,  its  neck  is  ligated, 

and  it  is  cut  off  in  front  of 
the  ligature.  The  spermatic 
cord  is  lifted  (Fig.  245,  a)  ;  the 
border  of  the  rectus  muscle, 
the  edges  of  the  internal  ob- 
lique and  the  transversalis 
muscles,  and  the  transversahs 
fascia,  are  sutured  to  the  lower 
shelf  of  Poupart's  ligament  be- 
low the  cord  (Fig.  245,  b).  The 
border  of  the  external  oblique 
is  sutured  to  the  upper  shelf  of 
Poupart's  ligament  above  the 
cord  (Fig.  245,  c).  The  skin  is 
sutured  by  interrupted  stitches 
of  silkworm-gut  or  the  edges 
of  the  wound  are  approximated 
by  a  subcuticular  stitch  of  cat- 
gut or  silver  wire.  In  this 
operation  the  author  is  accus- 
tomed to  treat  the  sac  as  in  Macewen's  operation,  carrying 
out  the  rest  of  the  procedure  as  directed  above.  In  a  pure 
Bassini  operation  the  funnel-shaped  depression  in  the  peri- 
toneum at  the  point  of  emergence  of  the  cord  remains  and 
predisposes  to  hernia,  but  the  use  of  Macewen's  plan  for 
treating  the  sac  obviates  this.  Halsted  makes  a  new  in- 
guinal canal  and  a  new  internal  ring,  removes  the  larger 
veins  to  lessen  the  diameter  of  the  cord,  cuts  away  the  sac 
and  sutures  it  exactly  as  the  peritoneum  is  sutured  after 
a  laparotomy,  places  the  cord  between  the  external  ob- 
lique muscle  and  the  integument,  and  closes  the  skin 
incision  with  a  subcuticular  suture.  Halsted's  subcutic- 
ular suture  is  almost  identical  with  the  subcuticular  suture 
of  Kendal  Franks  of  Dublin.  Chassaignac,  as  long  ago  as 
185 1,  recommended  a  subcutaneous  suture.  Halsted's  suture 
is  not  subcutaneous,  but  subcuticular  or  intradermal.  The 
material  employed  may  be  silver  wire,  catgut,  or  silk.  It  is 
inserted  by  means  of  a  medium-sized  Hagedorn  needle  held 
in  a  needle-holder.  It  is  carried  through  the  derma  at  the 
one  margin  of  the  wound  and  then  of  the  other,  and  so  on. 
When  it  is  inserted  the  ends  of  the  suture  are  pulled  and 
the  wound  is  approximated.  In  introducing  this  suture 
the  needle  does  not  pass  through  the  epiderm,  and  hence 


DISEASES  AND   INJURIES   OF   THE   ABDOMEN.       705 

there  is  no  danger  of  infecting  the  wound  with  the  staphy- 
lococcus epidermidis  albus.  Kocher  exposes  the  aponeu- 
rosis of  the  external  oblique,  makes  a  small  incision  through 
the  aponeurosis  above  and  external  to  the  internal  ring,  and 
draws  the  sac  through  this  incision  and  sutures  it  in  place. 

Fowler's  operation  is  as  follows :  an  incision  is  made 
parallel  with  Poupart's  ligament  from  the  spine  of  the  pubis 
to  the  level  of  the  internal  ring,  and  a  flap  is  turned  up.  The 
inguinal  canal  is  opened  and  the  sac  and  cord  isolated.  The 
sac  is  opened,  its  contents  reduced,  it  is  cut  off,  and  its 
edges  grasped  with  forceps.  The  deep  epigastric  artery  and 
vein  are  sought  for,  each  is  tied  in  two  places  and  divided 
between  the  ligatures.  The  index  finger  is  introduced  into 
the  belly,  and  on  this  as  a  guide  the  floor  of  the  canal  is 
divided  (transversalis  fascia,  subserous  tissue,  and  peritoneum). 
The  cord  is  placed  in  the  peritoneal  cavity.  The  edges  of 
the  opening  are  sutured  so  that  broad  serous  surfaces  are 
approximated,  through-and-through  sutures  being  passed 
from  side  to  side.  The  cord  is  brought  out  at  the  inner 
end  of  the  incision,  the  lower  angle  of  the  cut  being  at  such 
a  level  that  the  cord  curves  upward  and  forward  as  it  leaves 
the  abdomen.  The  inguinal  canal,  the  gap  in  the  aponeuro- 
sis, and  the  skin  are  closed.^ 

After  a  radical,  cure  the  patient  should  remain  in  bed  four 
weeks. 

Radical  Ctire  of  Umbilical  Hernia. —  Make  an  elliptical 
incision  through  the  skin  around  the  mass.  Endeavor  to 
separate  the  sac  from  the  superficial  tissues.  If  this  cannot 
be  done,  open  the  sac  and  separate  it  from  the  contents. 
Even  if  the  sac  can  be  stripped  from  the  skin,  always  open 
it  and  separate  the  contents.  Return  any  bowel  which  may 
be  present,  and  do  not  forget  that  there  may  be  a  small 
portion  of  bowel  completely  incased  in  omentum.  Tie  into 
segments  and  cut  off  the  superfluous  omentum  and  return 
the  stump  into  the  belly.  Excise  the  umbilicus  (omphalec- 
tomy). Suture  the  peritoneum  with  a  continuous  catgut 
suture.  Close  the  musculofascial  wall  with  two  layers  of 
interrupted  kangaroo-tendon  sutures.  Close  the  skin  by 
interrupted  sutures  of  silkworm-gut  or  a  subcuticular  stitch. 

Radical  Cure  of  Femoral  Hernia. — Cheyne  ligates  the 
neck  of  the  sac,  stitches  the  stump  to  the  abdominal  wall, 
dissects  out  a  flap  from  the  pectineus  muscle,  stitches  this 
flap  to  Poupart's  ligament  and  to  the  abdominal  wall,  and 
thus   fills   up  the  crural  canal.     Bassini  makes  an  incision 

1  Annals  of  Surgery,  Nov.,  1897. 
45 


706  MODERN  SURGERY. 

parallel  with  Poupart's  ligament,  ties  the  neck  of  the  sac, 
cuts  below  the  ligature,  and  returns  the  stump  into  the  belly. 
He  attaches  by  deep  sutures  Poupart's  hgament  to  the  pec- 
tineal aponeurosis  as  high  up  as  the  pectineal  eminence,  the 
cord  or  round  ligament  being  drawn  out  of  the  way.  Super- 
ficial sutures  are  passed  between  the  pubic  portion  and  the 
iliac  portion  of  the  fascia  lata. 

The  operation  of  Fabricius  is  as  follows  :  an  incision  is 
begun  over  the  pubic  spine  and  is  carried  outward  for  five 
inches  parallel  with  Poupart's  ligament.  The  sac  is  exposed, 
isolated,  and  opened,  and  its  contents  are  reduced,  its  neck 
is  ligated,  the  sac  is  cut  off,  and  the  stump  is  dropped  back. 
An  incision  is  now  made  below  Poupart's  ligament  so  as  to 
separate  this  structure  and  the  fascia  lata,  and  the  flap  of 
fascia  is  turned  down.  The  crural  sheath  and  the  vessels  are 
retracted,  and  the  origin  of  the  pectineus  muscle  is  sutured 
to  Poupart's  ligament.  The  flap  of  fascia  lata  is  sutured 
to  the  aponeurosis  of  the  external  oblique,  and  the  skin  is 
sutured. 

Irreducible  Hernia. — The  swelling  in  irreducible  rupture 
presents  the  usual  evidences  of  hernia,  shows  an  impulse  on 
coughing,  but  cannot  be  replaced  in  the  abdomen.  Some- 
times a  portion  is  reducible  and  a  portion  is  irreducible.  A 
hernia  may  become  irreducible  because  of  the  size  of  the 
mass,  because  of  adhesions,  or  because  of  great  growth  of 
omental  fat.  An  irreducible  hernia  is  liable  to  be  bruised 
and  to  cause  much  distress  and  pain,  and  is  always  a  menace 
to  life  because  of  the  danger  of  obstruction  and  strangulation. 
A  small  irreducible  hernia  can  be  supported  by  a  hollow 
padded  truss ;  a  large  hernia  of  this  variety  is  carried  in  a 
bag-truss.  The  patient  must  not  take  very  active  exer- 
cise, must  keep  the  bowels  regular,  and  must  live  upon 
a  plain  diet.  Most  of  these  cases  should  be  treated  by 
operation. 

Incarcerated  or  Obstructed  Hernia. — Obstruction  takes 
place  by  the  damming  up  of  feces  or  of  undigested  food, 
the  fecal  current  being  arrested,  but  the  blood-current  in 
the  walls  of  the  bowel  being  undisturbed.  Incarceration 
is  commonest  in  irreducible  hernia,  umbilical  hernia,  and 
during  the  existence  of  constipation.  The  tumor  enlarges 
and  becomes  tender,  painful,  and  dull  on  percussion ;  press- 
ure diminishes  it  in  size ;  it  is  irreducible,  but  still  pre- 
sents impulse  on  coughing.  The  abdomen  is  somewhat 
distended  and  painful ;  there  are  nausea,  constipation,  and 
not  unusually  slight  vomiting.     Constitutional  disturbance 


DISEASES  AND   INJURIES   OF   THE   ABDOMEN.       JO'J 

is  slight  and  constipation  is  not  absolute,  gas  at  least 
usually  passing.  Vomiting  is  not  fecal.  The  trcatnioit  is 
rest  in  bed  in  a  position  to  relax  the  belly,  an  ice-bag  over 
the  hernia,  and  a  little  opium  for  pain.  Do  not  give  a 
particle  of  food  for  twenty-four  hours ;  when  the  active 
symptoms  subside  give  an  enema,  and  after  this  acts  a  dose 
of  castor  oil.  Do  not  employ  taxis,  as  bruising  the  bowel 
may  produce  strangulation. 

Inflamed  Hernia. — Inflammation  of  a  hernia  is  local  peri- 
tonitis due  to  injury  of  an  irreducible  hernia.  The  mass 
becomes  tender,  painful,  and  hot.  In  enterocele  much  fluid 
forms  ;  in  epiplocele  the  mass  becomes  hard.  The  hernia 
cannot  be  reduced ;  there  is  constipation,  often  vomiting, 
usually  fever,  but  the  mass  still  shows  impulse  on  coughing. 
Vomiting  is  not  fecal.  Some  gas  is  usually  passed  through  the 
bowels.  Constitutional  symptoms  are  slight.  The  trcatiticnt 
is  rest  in  bed  with  abdominal  relaxation,  an  ice-bag  to  the 
tumor,  a  small  amount  of  opium  by  the  mouth  if  pain  is. 
severe,  an  enema,  and  when  this  acts  a  saline.  If  pus  forms, 
incise  and  drain. 

Strangulated  hernia  is  a  condition  in  which,  if  the  hernia 
contains  bowel,  not  only  is  the  fecal  circulation  arrested, 
but  the  circulation  of  blood  in  the  bowel-wall  is  also  ar- 
rested. The  bowel  is  irreducible  and  obstructed,  and  the 
blood  ceases  to  circulate.  If  the  hernia  contains  omentum, 
the  omental  vessels  are  tightly  constricted.  Strangulation 
is  commonest  in  old  inguinal  ruptures  in  active,  middle-aged 
men,  and  is  more  frequent  in  enteroceles  than  in  epiploceles. 
It  may  be  due  to  entry  into  the  sac  of  more  intestine  or 
omentum,  which  has  been  forced  down  by  sudden  movement 
or  violent  effort.  It  may  be  due  to  active  peristalsis  or  to 
congestion,  and  it  may  arise  from  inflammation  or  from  in- 
carceration. The  constriction  is  usually  at  the  neck  of  the 
sac,  in  the  outside  tissues,  or  even  in  the  sac  itself  In  an 
hour-glass  hernia  the  constriction  is  in  the  body  of  the  sac. 
Adhesions  within  the  sac  may  cause  strangulation.  Spas- 
modic contraction  of  the  tissues  about  the  neck  of  the  sac 
is  an  exploded  hypothesis.  When  strangulation  once  begins 
the  hernia  swells,  a  furrow  forms  on  the  bowel  at  the  seat 
of  constriction,  the  bowel  and  omentum  below  the  con- 
striction become  deeply  congested  and  edematous,  and, 
finally,  the  hernia  passes  into  a  state  of  moist  gangrene. 
The  gangrene  may  be  in  spots  or  the  entire  mass  may  be 
gangrenous.  The  sac  is  apt  to  inflame,  and  inflammation 
produces  fluid  and   lymph ;  serum  accumulates  in  the  sac, 


7o8  MODERN  SURGERY. 

being  first  clear,  then  bloody,  and  finally  brown  and  foul. 
When  gangrene  is  once  established  the  bowel  is  in  danger 
of  rupturing.  At  the  point  of  contraction  there  may  be 
a  line  of  ulceration.  A  strangulated  femoral  hernia  becomes 
gangrenous  more  rapidly  than  does  a  strangulated  inguinal 
hernia. 

Sympionis. — An  individual  who  has  a  hernia  is  seized  with 
violent  colicky  pain  about  the  umbiHcus,  and  the  paroxysms 
of  colic  become  more  and  more  frequent,  until  finally  the  pain 
may  become  continuous.  The  hernia  is  found  to  be  irre- 
ducible ;  larger  than  usual,  tender,  painful,  and  dull  on  per- 
cussion, and  without  impulse  on  coughing.  Eructations  of 
gas  are  frequent.  Uncontrollable  vomiting  and  prostration 
come  on.  Vomiting,  as  a  rule,  is  an  early  symptom,  and  one 
which  increases  in  severity.  Occasionally  it  only  follows 
the  swallowing  of  liquids.  In  rare  cases  it  does  not  arise  for 
twenty-four  to  forty-eight  hours.  During  the  course  of  a 
'  strangulation  vomiting  may  cease  for  a  day  or  more,  and  it 
not  unusually  ceases  toward  the  end,  when  prostration  is 
profound.  The  early  vomiting  is  due  to  reflex  causes,  the 
later  vomiting  is  due  to  waves  of  peristalsis  which  produce 
regurgitation  (Macready).  The  vomiting  is  first  of  the  ali- 
mentary contents  of  the  stomach,  next  of  mucus  and  bil- 
ious matter,  and  finally  of  the  contents  of  the  small  bowel 
(fecal  or  stercoraceous  vomiting).  Stercoraceous  vomiting 
rarely  arises  until  strangulation  has  lasted  forty-eight 
hours,  and  may  not  appear  until  much  later.  "  It  is  sel- 
dom met  with  in  ingiSnal,  more  often  in  femoral,  and  more 
often  still  in  obturator  hernia  "  (Macready).  Prostration  is  a 
marked  symptom  of  a  strangulated  hernia,  and  it  increases 
hour  by  hour  and  goes  on  to  collapse.  Early  in  the  case 
there  may  be  some  elevation  of  temperature,  but  later  it 
becomes  normal  or  subnormal.  The  pulse  is  small,  irregu- 
lar, rapid,  and  very  weak — the  extremities  cold,  the  face 
Hippocratic.  Constipation  is  absolute,  no  gas  even  being 
passed,  though  in  the  very  beginning  there  may  be  some 
diarrheal  passages  from  below  the  constriction.  The  urine 
is  scanty  and  high-colored,  and  contains  only  a  small 
amount  of  the  chlorids  ;  the  tongue  becomes  dry  and  brown  ; 
the  thirst  is  torturing ;  and  the  patient  often  has  an  urgent 
desire  to  go  to  stool.  Pains  in  the  abdomen  and  in  the 
hernia  become  violent,  and  collapse  rapidly  increases.  When 
gangrene  begins  the  symptoms  apparently  lessen  in  violence : 
there  is  a  "delusive  calm."  Vomiting  usually  ceases,  though 
regurgitation  may  take  its  place  ;  hiccough  begins  ;  the  pain 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       709 

abates  or  disappears ;  the  pulse  becomes  very  feeble  and 
intermittent;  collapse  deepens,  and  delirium  is  usual.  It  is 
a  safe  clinical  rule  that  in  strangulated  hernia  cessation  of 
pain  without  the  relief  of  constriction  or  the  use  of  opiates 
means  that  gangrene  has  begun.  In  a  pure  omental  hernia 
strangulation  produces  similar  but  less  decided  symptoms. 
In  Littre's  hernia  only  a  portion  of  the  circumference  of  the 
bowel  is  constricted,  usually  in  the  femoral  ring.  In  a 
strangulated  Littre's  hernia  constipation  is  rarely  absolute 
and  the  tumor  is  often  undiscovered.  In  some  cases  of 
strangulation  there  are  muscular  cramps  in  the  legs  (Berger). 
In  children  convulsions  are  not  unusual. 

Treatuicnt. — In  treating  strangulated  hernia  place  the 
patient  upon  his  back,  bend  the  knees  over  a  pillow,  and 
rigidly  interdict  the  administration  of  food.  An  attempt  is 
to  be  made  to  effect  reduction  by  gentle  manipulation  or 
taxis.  In  applying  taxis  to  a  femoral  or  inguinal  hernia,  flex 
and  adduct  the  thigh  of  the  affected  side.  In  applying  taxis 
to  an  umbilical  hernia,  both  thighs  should  be  flexed  upon 
the  abdomen.  Always  lower  the  shoulders  and  head  and 
raise  the  pelvis,  and  accomplish  this  by  lifting  the  foot 
of  the  bed  and  placing  pillows  under  the  pelvis.  Grasp 
the  neck  of  the  sac  with  the  fingers  and  thumb  of  one 
hand,  and  employ  the  other  hand  to  squeeze  the  hernia  and 
urge  it  toward  the  belly.  In  direct  inguinal  hernia  the 
pressure  should  be  backward  and  a  little  upward ;  in  umbil- 
ical hernia  it  should  be  backward;  in  oblique  inguinal  hernia 
it  should  be  upward,  outward,  and  backward ;  in  femoral 
hernia  it  should  be  downward  until  the  hernia  enters  the 
saphenous  opening,  and  then  "  backward  toward  the  pubic 
spine"  (MacCormac).  If  the  bowel  is  reduced,  it  passes 
from  the  hand  with  a  sudden  slip  and  enters  the  belly 
with  an  audible  gurgle ;  omentum,  when  reduced  slowly, 
glides  back  without  gurgling.  Taxis  is  never  to  be  con- 
tinued long,  and  it  is  not  even  to  be  attempted  in  cases  of 
great  acuteness,  in  cases  where  strangulation  has  lasted  for 
several  days,  in  cases  known  to  have  previously  been  irre- 
ducible, in  cases  associated  with  stercoraceous  vomiting,  or 
in  an  inflamed  or  gangrenous  hernia. 

If  taxis  fails,  obtain  the  patient's  permission  to  operate. 
Anesthetize;  try  taxis  again  while  ether  is  being  dropped 
upon  the  hernia  to  cause  cold ;  if  it  fails,  at  once  perform 
herniotomy.  Taxis  possesses  certain  dangers  :  it  may  rup- 
ture the  bowel ;  it  may  rupture  the  neck  of  the  sac  and 
force  the  bowel  through  the   rent ;   it  may  strip  the  peri- 


yiO  MODERN  SURGERY. 

toneum  from  around  the  hernial  orifice  and  force  the  bowel 
between  the  detached  peritoneum  and  the  abdominal  wall ; 
it  may  reduce  a  hernia  into  the  belly  when  the  bowel  is 
still  strangulated  by  adhesions ;  it  may  reduce  the  hernia 
en  masse  or  en  bloc,  the  sac  and  strictured  bowel  being 
forced  together  into  the  abdomen.  By  reduction  en  bissac 
is  meant  the  forcing  of  a  congenital  hernia  into  a  congenital 
pouch  or  diverticulum.  In  any  of  the  above  accidents 
strangulation  may  persist  after  apparent  reduction  by  taxis, 
and  this  condition  calls  for  instant  laparotomy — in  most 
instances  through  the  hernial  aperture.  If  taxis  is  success- 
ful, put  the  patient  to  bed,  apply  a  pad  and  bandage,  allow 
the  patient  to  take  no  food  until  vomiting  ceases,  merely 
permitting  him  to  suck  bits  of  ice,  and  keep  him  on  a  liquid 
diet  for  several  days.  At  the  end  of  the  first  week  give 
solid  food ;  if  the  bowels  have  not  acted  by  this  time,  ad- 
minister an  enema,  following  it  by  a  dose  of  Epsom  salts  if 
there  is  no  pain  and  no  disposition  to  vomit.  Some  sur- 
geons advocate  inversion  as  a  valuable  aid  to  taxis. 

Herniotomy. — The  instruments  required  in  herniotomy  are 
a  scalpel,  a  hernia-knife  and  director  (Fig.  242,  b),  hemostatic 
and  dissecting-forceps,  blunt  hooks,  scissors,  a  dry  dissector, 
partly-curved  needles,  and  a  needle-holder.  Drainage-tubes 
should  be  ready.  In  the  operation  the  patient  lies  upon  his 
back  with  the  shoulders  raised,  the  surgeon  standing  to 
the  patient's  right  side.  In  oblique  inguinal  hernia  it  has 
been  the  custom  since  the  days  of  Scultetus  to  raise  a  fold  of 
skin  at  right  angles  to  the  axis  of  the  external  ring  and 
transfix  it,  the  wound  which  results  being  extended  until  it 
becomes  three  inches  in  length.  This  incision  possesses 
no  special  merit.  It  is  better  to  cut  from  without  inward, 
and  to  make  the  same  incision  as  for  the  performance  of  a 
radical  cure  in  a  non-strangulated  case.  The  tissues  are 
divided  until  the  sac  is  reached,  and  no  attempt  is  made  to 
specially  identify  them.  The  sac  is  known  by  the  fat  which 
usually  covers  it,  by  the  arborescent  arrangement  of  its  ves- 
sels, by  the  fact  that  it  can  be  pinched  up  between  the  finger 
and  thumb  and  the  layers  rolled  over  each  other,  and  by  the 
fluid  within  the  sac.  Should  the  sac  be  opened  ?  In  very 
recent  cases  it  is  usually  unnecessary,  but  if  there  is  any 
doubt  as  to  the  condition  of  the  bowel,  or  if  a  radical  cure 
is  to  be  attempted,  open  the  sac  and  be  certain  as  to  the  con- 
dition of  its  contents.  The  general  rule  should  be  to  open 
the  sac.  The  sac  is  opened  and  the  contents  examined  for 
fecal  odor  (which  is  not  unusual)  and  for  gangrenous  smell ; 


DISEASES  AND   INJURIES   OF  THE  ABDOMEN.       711 

the  thickness  of  the  bowel  is  estimated,  and  the  color  and 
luster  are  determined.  In  oblique  inguinal  hernia  nick  the 
constriction  upward  and  outward,  as  shown  in  P'ig.  246.  In 
direct  inguinal  hernia  the  cut  is  made  upward  and  inward. 
Always  pull  the  bowel  down  and  examine  the  scat  of  con- 
striction to  see  what  damage  has  been  inflicted  at  that  point. 
If  the  bowel  glistens,  if  the  proper  color  comes  back  after  irri- 
gation with  very  hot  water,  and  if  there  are  no  spots  of  gan- 
grene, restore  the  bowel  to  the  abdomen,  and  do  a  radical 
cure.  If  the  bowel  is  in  a  doubtful  condition,  fasten  it  to 
the  incision,  apply  a  dressing,  and  watch  the  development  of 
events.  If  the  bowel  is  gangrenous,  our  action  depends  upon 
the  condition  of  the  patient.  If  the  patient  is  in  good  condi- 
tion, resect  the  gangrenous  portion,  and  perform  end-to-end 
anastomosis  by  means  of  a  Murphy  button.  If  the  patient's 
condition  is  bad,  make  an  artificial  anus,  and  at  a  later  period 
perform  anastomosis.  An  arti- 
ficial anus  can  be  made  by  the 
method  of  Bodine  (page  695). 
In  most  cases  do  not  open  the 
bowel  at  once,  because  it  may 
recover  in  a  day  or  two,  when 
it  can  be  restored  to  the  belly ; 
or  it  may  slough  and  form  an 
artificial  anus.  In  such  a  doubt- 
ful case,  fasten  the  bowel  to  the 

belly-wall    with    sutures,  dust    it       FiG^46.-Herniotomyiningu.nalhernia. 

with  iodoform,  dress  it  with  hot 

antiseptic  fomentations,  and  await  future  developments.  Gan- 
grenous omentum  requires  ligation  and  resection.  If  the 
bowel  is  fit  to  reduce,  push  it  just  inside  the  ring,  irrigate 
the  parts,  insert  a  drain,  and  stitch.  In  most  cases  perform 
a  radical  cure.  In  femoral  Jicniia  we  can  make  the  incision 
one  inch  internal  to,  and  parallel  with,  the  femoral  vessels, 
and  crossing  the  tumor  and  ligament  (Barker) ;  but  it  is  bet- 
ter to  make  the  incision  of  Fabricius  for  radical  cure.  Divide 
the  constriction  by  cutting  upward  and  a  little  inward.  In 
iinibilical  hernia  make  a  slightly-curved  incision  a  little  to 
one  side  of  the  middle  of  the  tumor,  open  the  sac,  separate 
adhesions,  and  divide  the  constriction  by  cutting  upward  or 
downw^ard,  and  sometimes  also  laterally. 

After  an  operation  for  strangulated  hernia  put  the  patient 
to  bed ;  bend  the  knees  over  a  pillow ;  give  no  food  by  the 
mouth  for  thirty-six  hours  (MacCormac),  only  allowing  the 
patient  bits  of  ice  to  suck  ;  give  nutrient  enemata  containing 


712  MODERN  SURGERY. 

brandy ;  and  use  morphin  hypodermatically.  If  the  bowels 
have  not  acted  by  the  end  of  the  first  week,  give  an  enema 
and  follow  this  by  a  saline.  Remove  the  drainage-tube  on 
the  third  day.  At  the  end  of  about  three  weeks,  if  a  radical 
cure  has  not  been  attempted,  get  the  patient  up,  first  apply- 
ing a  pad  and  a  spica  bandage  to  the  groin,  and  later  a  truss. 
If  a  radical  cure  has  been  made,  the  patient  should  stay  in 
bed  for  one  month.  A  truss  should  not  be  worn  if  a  radical 
cure  has  been  made. 

Anatomical  Varieties  of  Hernia. — In  direct  inguinal  hernia 
the  bowel  passes  out  through  Hesselbach's  triangle  internal 
to  the  deep  epigastric  artery.  It  enters  the  inguinal  canal 
low  down,  and  passes  outside  the  conjoined  tendon  or  forces 
the  conjoined  tendon  before  it  or  splits  through  the  tendon. 
The  neck  of  the  sac  is  internal  to  the  deep  epigastric  artery. 
The  coverings  of  this  hernia,  when  it  passes  external  to  the 
conjoined  tendon,  are  the  same  as  for  indirect  inguinal  hernia ; 
when  a  direct  hernia  pushes  before  it  the  conjoined  tendon, 
its  coverings  are  skin,  superficial  fascia,  intercolumnar  fascia, 
conjoined  tendon,  tranversalis  fascia,  subserous  tissue,  and 
peritoneum.  In  indirect  ingidnal  liernia  the  bowel  passes 
through  the  internal  abdominal  ring  external  to  Hesselbach's 
triangle  and  external  to  the  deep  epigastric  artery.  It  passes 
down  the  inguinal  canal  and  emerges  from  the  external  ring ; 
it  may  enter  the  scrotum  or  labium  (scrotal  or  labial  hernia), 
or  it  may  not.  The  neck  of  the  sac  is  external  to  the  deep 
epigastric  artery.  Its  coverings  are  skin,  superficial  fascia, 
intercolumnar  fascia,  cremaster  muscle,  infundibuliform  fascia, 
subserous  tissue,  and  peritoneum.  Congeintal  or  encysted  in- 
guinal henna  is  a  hernia  into  an  unclosed  vaginal  process. 
The  bowel  in  congenital  hernia  has  one  layer  of  peritoneum 
in  front  of  it.  The  testicle  is  posterior.  In  funicidar  hernia 
the  vaginal  process  is  closed  below  and  open  above,  and  a 
hernia  takes  place  into  the  unclosed  funicular  process.  The 
bowel  has  one  layer  of  peritoneum  in  front  of  it.  The  testi- 
cle is  posterior.  In  infantile  hernia  the  vaginal  process  is 
occluded  above,  and  not  below,  and  the  septum  of  occlusion 
is  pushed  down  by  the  hernia.  In  infantile  hernia  the  bowel 
has  three  layers  of  peritoneum  in  front  of  it.  The  testicle  is 
in  front.  Always  remember  that  congenital  hernia  may  not 
appear  for  several  months  after  birth.  Congenital  hernia 
conceals  or  buries  the  testicle ;  acquired  hernia  does  not. 
\vi  femoral  hernia  the  bowel  descends  along  the  femoral  canal, 
and  the  neck  of  the  sac  is  at  the  femoral  ring.  The  neck 
of  a  femoral  rupture  is  always  external  to  the  pubic  spine ; 


DISEASES  AND  INJURIES  OF  THE  RECTUM  AND  ANUS.    713 

tlie  neck  of  an  inguinal  rupture  is  always  internal  to  the 
pubic  spine.  Femoral  hernia  is  never  congenital.  Its  cov- 
erings are  skin,  superficial  fascia,  cribriform  fascia,  crural 
sheath,  septum  crurale,  subserous  tissue,  and  peritoneum. 
Umbilical  hernia  may  be  congenital  (the  ventral  plates 
having  closed  incompletely),  infantile  (the  citatrix  of  the 
umbilicus  having  stretched),  or  acquired.  Ventral  hernia 
is  a  protrusion  at  any  part  of  the  anterior  abdominal  wall 
e.Kcept  at  the  umbilicus  or  above  it.  Epigastric  hernia  is 
a  protrusion  of  peritoneum  in  the  space  bounded  by  the 
ensiform  cartilage,  the  ribs,  and  the  umbilicus.  The  sac  of 
peritoneum  may  be  empty,  may  contain  omentum,  or  omen- 
tum and  bowel.  The  stomach  very  rarely  passes  into  the 
sac.  The  protrusion  is  usually,  but  not  invariably,  through 
the  linea  alba.  Properitoneal  her/iia  is  a  sac  between  the  per- 
itoneum and  transversalis  fascia.  This  form  of  hernia  is  some- 
times produced  by  making  taxis  on  an  inguinal  hernia,  when 
the  internal  ring  is  small  or  is  blocked  by  an  undescended 
testicle.  In  properitoneal  inguinal  hernia,  which  is  the  most 
common  form,  there  are  two  sacs  detectable,  one  in  the 
scrotum,  the  other  parallel  with  Poupart's  ligament,  and  as 
one  sac  is  emptied  the  other  distends  (Breiter  of  Zurich). 
Obturator  hernia  passes  through  the  obturator  membrane 
or  the  obturator  canal,  and  is  felt  below  the  horizontal 
ramus  of  the  pubes,  internal  to  the  femoral  vessels.  Lnnibar 
hernia  occurs  at  the  edge  of,  or  through,  the  quadratus  lum- 
borum  muscle.  Sciatic  hernia  passes  through  the  great 
sacrosciatic  foramen.  In  diaphragmatic  hernia  some  viscera 
of  the  abdomen  pass  through  a  natural  or  an  accidental  open- 
ing into  the  thorax.  Pudendal  hernia  protrudes  into  the  lower 
part  of  the  labmm.  Perineal  hernia  presents  in  the  perineum, 
between  the  rectum  and  the  prostate  gland  or  between  the 
rectum  and  the  vagina.  Hernia  into  the  foramen  of  VVinslow 
is  very  rare. 


XXVIII.    DISEASES  AND   INJURIES   OF  THE   RECTUM 

AND   ANUS. 

Hemorrhoids,  or  Piles.— There  are  three  varieties  of 
varicose  tumors  of  the  rectum,  namely :  internal,  which  take 
origin  within  the  external  sphincter;  external,  which  take 
origin  without  the  external  sphincter;  and  mixed  hemor- 
rhoids, which  are  a  combination  of  the  two. 

External   hemorrhoids  are  covered   with  skin.      Internal 


714  MODERN  SURGERY. 

hemorrhoids  are  covered  with  mucous  membrane.  The  term 
external  hemorrhoids  is  not  strictly  accurate,  as  hemorrhage 
does  not  occur  in  external  piles,  and  all  external  piles  are  not 
related  to  the  external  hemorrhoidal  veins.  An  external 
pile  may  involve  the  veins  or  the  skin.  If  the  veins  are  in- 
volved, there  may  be  varicosity  of  the  plexus,  a  condition  due 
to  straining,  often  associated  with  internal  piles  and  produc- 
tive of  no  particular  annoyance.  Symptoms  appear  when 
phlebitis  arises ;  phlebitis  causes  thrombus,  and  the  vein  com- 
monly ruptures. 

External  Hemorrhoids. — When  a  vein  inflames  the  parts 
are  itchy,  painful,  and  swollen,  and  defecation  increases  the 
pain.  When  the  vein  ruptures  a  livid,  soft  enlargement  ap- 
pears near  the  edge  of  the  anus,  accompanied  by  decided  pain 
and  other  evidences  of  inflammation.  These  blood-tumors 
may  get  well  if  let  alone,  or  they  may  suppurate.  External 
piles  are  apt  to  be  multiple,  and  cause  no  pain  except  when 
inflamed.  When  the  superfluous  tags  of  skin  around  the 
anus  enlarge,  they  give  rise  to  much  pain  and  inflammation. 
These  cutaneous  outgrowths  are  often  spoken  of  as  a  form 
of  external  piles.  These  cutaneous  piles  are  due  to  some 
inflammation,  and  are  frequently  secondary  to  inflammation, 
of  the  anus  or  in  the  rectum. 

Symptoms  and  Treatment. — An  inflammatory  enlargement 
is  detected,  which  is  tender  and  painful.  Pain  is  increased  by 
defecation.  These  piles  do  not  bleed.  In  treating  external 
hemorrhoids  some  surgeons  merely  use  remedies  to  combat 
the  inflammation.  An  old  plan  of  treatment  is  to  incise  the 
blood-tumor,  turn  out  the  clot,  and  pack  with  a  bit  of  iodo- 
form gauze.  Matthews  freezes  the  part  or  injects  cocain, 
catches  up  the  blood-tumor  with  a  volsellum,  excises  the 
tumor  and  the  tabs  of  inflamed  skin,  dusts  the  part  with 
iodoform,  and  dresses  it  with  antiseptic  gauze.  The  bowels 
should  not  be  allowed  to  move  for  two  days.  Never  inject 
external  piles  with  carbolic  acid :  it  causes  great  inflamma- 
tion, excessive  pain,  and  is  not  free  from  danger.  If  the 
patient  declines  operation,  order  rest,  a  non-stimulating  diet, 
avoidance  of  tobacco  (Matthews),  the  use  of  saline  purga- 
tives, injections  into  the  rectum  of  cold  water  several  times  a 
day,  sponging  of  the  anus  frequently  with  hot  water,  and  the 
application  of  hot  poultices.  As  the  acute  symptoms  begin 
to  disappear  use  lead-water  and  laudanum  ;  when  they  have 
nearly  subsided  apply  zinc  ointment.  Extract  of  hamamelis 
is  a  valuable  application  to  external  piles. 

Internal  hemorrhoids  are  varicose  tumors  of  the  internal 


DISEASES  AXD  INJURIES  OF  THE  RECTUM  AND  ANUS.    7  I  5 

hemorrhoidal  plexus,  and  are  found  internal  to  the  external 
sphincter,  just  within  the  anus,  and  they  prolapse  easily. 
They  are  not  simple  varicosities,  but  new  tissue  has  been 
formed,  and  they  are  in  reality  angeiomata.  They  are 
covered  with  mucous  membrane.  Capillary  piles  are  small, 
sessile,  with  a  surface  like  a  mulberry,  and  bleed  freely. 
Children  are  not  very  liable  to  develop  piles  excepting  this 
capillary  form.  Venous  piles  are  the  most  common  variety. 
They  extend  from  just  above  the  anal  margin  of  the  rectum 
for  an  inch  or  more.  They  are  purple  in  color,  soft,  irregular 
in  outline,  and  are  usuall}'  multiple.  They  bleed  when  irri- 
tated by  hard  fecal  masses,  but  not  so  easily  as  the  capil- 
lar}' piles.  Each  pile  is  composed  of  a  varicose  vein,  some 
little  fibrous  tissue,  and  a  few  arterial  twigs.  ATtcrial  piles 
are  very  unusual.  They  are  large,  smooth,  pedunculated, 
bleed  easily  and  freely,  and  contain,  besides  a  distended  vein, 
arteries  of  some  size. 

An}-thing  producing  venous  congestion  in  the  rectum — 
constipation,  diseases  of  the  rectum,  enlargement  of  the 
prostate,  pregnancy,  tumors  of  the  womb,  congestion  of  the 
liver,  cirrhosis  of  the  liver,  certain  diseases  of  the  heart  and 
lungs,  sedentar}'  occupations,  relaxing  climate,  and  stricture 
of  the  urethra — will  cause  hemorrhoids. 

Syniptoins  ami  Trcatvicnt. — If  there  is  no  bleeding  and  no 
protrusion,  the  piles  give  no  trouble.  The  first  s}-mptom  is 
usually  hemorrhage,  and  rectal  examination  by  the  finger 
and  by  the  speculum  will  make  clear  the  condition.  After  a 
time,  during  defecation,  the  piles  protrude  ;  they  may  reduce 
themselves  when  the  patient  stands  up,  or  it  may  be  neces- 
sary to  push  them  in.  Pain  does  not  exist  in  uncomplicated 
cases,  and  pain  during  or  after  protrusion  means  "  abrasion, 
fissure,  or  ulceration"  (^Matthews).  Palliative  treatment  will 
not  cure,  but  it  will  give  great  comfort.  Some  people  only 
suffer  at  rare  times  when  the  liver  is  congested,  and  such 
subjects  will  not  submit  to  operation.  Remove,  if  possible, 
the  cause  (alcohol,  irritating  foods,  want  of  exercise,  etc.) ; 
restrict  the  diet;  insist  on  regular  exercise;  give  a  course  of 
Carlsbad  salt,  and  follow  this  by  the  stomach  use  of  bichlo- 
rid  of  mercury  (gr.  4^  after  each  meal).  Prevent  constipation 
by  a  nightly  dose  of  fluid  extract  of  cascara.  After  each 
movement  wash  the  parts  and  syringe  out  the  rectum  with 
cold  water,  and  dr}^  outwardly  with  a  soft  rag.  If  the  hemor- 
rhoids prolapse,  after  restoring  them  and  injecting  water, 
insert  a  suppositor}'  containing  gr.  v  of  the  extract  of  ham- 
amelis,  and    use    another    suppository   at    bedtime.      When 


ji6 


.MODERN  SURGERY. 


the  piles  prolapse  and  inflame,  rub  Allingham's  ointment  on 
the  parts  (3ij  each  of  ext.  of  conium  and  ext.  of  hyoscyamus, 
3j  of  ext.  of  belladonna,  and  5J  of  cosmoHn).  Matthews 
uses  gr.  xij  of  cocain,  3j  of  iodoform,  3ss  of  ext.  of  opium, 
and  3J  of  cosmolin.  If  the  piles  are  protruding  and  reduc- 
tion cannot  be  effected,  put  the  patient  to  bed,  give  a  hypo- 
dermatic injection  of  morphin,  and  apply  hot  poultices.  If 
reduction  cannot  soon  be  effected,  operate. 

Operative  Treatment. — Give  a  saline  the  morning  before, 
and  an  enema  the  evening  before,  the  operation,  and  wash  out 
the  rectum  well  the  morning  of  the  operation.  In  treating 
by  injection  of  carbolic  acid  the  tumors  are  drawn  out  or  the 
patient  strains  them  out,  an  injection  is  given  by  a  hypoder- 
matic syringe  into  the  center  of  the  pile,  and  as  each  pile 
is  injected  it  is  pushed  into  the  rectum.  The  dose  for  each 
pile  is  lo  drops  of  a  solution  containing  3  parts  of  glycerin, 
3  of  water,  and  i  of  pure  carbolic  acid.  The  injection  is 
rarely  curative,  is  very  painful,  and  may  produce  hemorrhage, 
phlebitis,  pyemia,  stricture,  and  even  death  (W.  T,  Bull). 
The  clamp  and  cautery  are  used  in  interno-external  piles. 
The  patient  is  anesthetized,  the  sphincter  is  stretched,  and  the 
pile  is  caught  with  forceps  and  drawn  outside  of  the  sphincter. 
Smith's  clamp  is  applied  with  the  ivory  surface  against  the  mu- 
cous membrane  of  the  bowel, 
the  pile  is  cut  off,  and  the  stump 
is  seared  with  the  Paquelin  cau- 
tery at  a  dull-red  heat.  Excis- 
ion is  preferred  by  Allingham. 
He     stretches     the     sphincter, 


Fig.  247. — Extirpation  of  hemorrhoids 
(Esmarch  and  Kowalzig.) 


Fig.  248. — SS,  the  lower  circular  incision 
along  Hilton's  white  line  ;  M,  tube  of  mucous 
membrane  dissected  from  the  sphincter  BB. 
Dotted  line  showing  the  place  for  the  upper 
circular  incision  (Edmund  Andrews). 


holds  it  open  with  a  retractor,  catches  up  the  pile,  cuts  it 
off,  and  twists  the  bleeding  vessels.     Some  prefer  to  pass 


DISEASES  AND  INJURIES  OF  THE  RECTUM  AND  ANUS.   JIJ 

a  silk  or  catgut  suture,  cut  off  the  tumor,  and  tie  the  thread 
(Fig.  247).  White  he  iiiVs  operation  is  suited  to  severe  cases, 
when  the  piles  are  extremely  large  and  form  a  protruding  cir- 
cular mass.  Only  a  surgeon  who  can  master  violent  hemor- 
rhage should  venture  to  perform  it.  The  entire  pile-bearing 
area  of  mucous  membrane  is  dissected  out,  and  the  cut  mar- 
gin of  mucous  membrane  is  pulled  down  and  stitched  to  the 
surface.  The  sphincter  must  be  dilated  as  a  preliminary 
(Fig.  248).  This  operation  is  sometimes  followed  by  dis- 
astrous consequences,  especially  by  fecal  incontinence.^ 

TJie  applieation  of  the  ligature  is  the  easiest  and  most 
generally  useful  method.  In  this  operation,  after  anes- 
thetizing, stretch  the  sphincter  and  treat  each  hemorrhoid 
separately.  Catch  a  pile  with  a  pair  of  forceps  or  a  vol- 
sellum,  pull  it  down,  and  cut  a  gutter  through  the  skin- 
margin  if  the  pile  is  of  the  mixed  variety  ;  tie  the  small 
piles  without  transfixing,  but  traiiisfix  the  large  piles ;  tie 
with  silk  (coarse  silk  for  the  large  piles,  finer  silk  for  the 
small  piles) ;  cut  off  the  tumor  beyond  the  thread,  and 
cut  the  ligatures  short.  Treat  the  other  piles  in  the 
same  manner.  Irrigate  with  hot  normal  salt  solution,  dust 
with  iodoform,  pack  a  piece  of  iodoform  gauze  into  the  rec- 
tum, and  apply  a  gauze  pad  and  a  T-bandage.  Give  some 
morphin  to  lock  up  the  bowels,  and  keep  the  patient  on  a 
light  diet  for  three  days,  at  the  end  of  which  time  a  saline 
may  be  given.  Just  before  the  bowels  act  remove  the  dress- 
ings and  give  an  enema  of  warm  water.  After  the  movement 
wash  out  the  rectum  first  with  peroxid  of  hydrogen  and 
next  with  hot  salt  solution,  dust  with  iodoform,  and  apply 
a  gauze  pad  over  the  anus.  Irrigate  daily  until  healing  is 
complete.  After  the  tenth  day  examine  with  a  speculum  to 
see  that  the  ligatures  have  come  away ;  if  any  are  found  in 
place,  remove  them. 

Prolapse  of  Anus  and  Rectum. — If  the  mucous  mem- 
brane is  prolapsed,  the  condition  is  called  "  prolapsus  ani ;" 
if  the  entire  thickness  of  the  rectal  wall  is  prolapsed,  it  is 
called  "  prolapsus  recti."  Prolapse,  which  is  apt  to  occur 
from  excessive  straining  at  stool,  is  commonest  in  feeble,  ill- 
nourished  children.  Piles  and  worms  may  be  complicated 
with  prolapse.  Straining  from  phimosis,  stone  in  the  blad- 
der, or  stricture  may  be  causative.  Prolapse  may  be  either 
large  or  small,  but  tends  to  recur  again  and  again,  and 
eventually  the  mucous  membrane  inflames,  ulcerates,  or 
sloughs.     Strangulation  of  the  prolapsed  part  may  occur. 

1  Andrews,  in  Matthew's  Medical  Quarterly,  Oct.,  1895. 


7 1  8  MODERN  SUR  GER  Y. 

Treatment.  —  Palliative  treatment  forbids  straining  at 
stool.  If  prolapse  occurs,  the  parts  are  bathed  in  cold 
water  and  restored.  Constipation  must  be  prevented  (ene- 
mata  of  water  or  glycerin  may  be  used).  If  a  prolapse  is 
caught  firmly,  place  the  patient  in  the  knee-chest  position, 
wash  the  mass  with  cold  water,  grease  it  with  cosmolin, 
insert  a  finger  into  the  rectum,  and  apply  taxis  around  the 
finger  (Matthews).  If  this  fails,  cover  a  finger  with  a  hand- 
kerchief and  insert  the  wrapped  digit  into  the  rectum ;  if  this 
prove  futile,  invert  the  patient.  Severe  cases  require  ether. 
After  reduction  apply  a  compress,  direct  it  to  be  worn 
except  when  at  stool,  and  before  each  act  of  defecation  give 
an  injection  of  cold  water  containing  an  astringent  (tannin 
or  fluid  ext.  hydrastis).  Some  cases  require  excision  of  the 
mucous  membrane,  the  divided  edge  of  this  membrane  being 
stitched  to  the  skin.  In  other  cases  the  protrusion  is  stroked 
with  the  cautery  and  restored.  In  persistent  cases  of  rectal 
prolapse  open  the  abdomen  and  attach  the  colon  to  the 
belly-wall  (colopexy). 

Ulcer  of  the  Rectum. — Simple  ulcer  is  due  to  abrasion 
with  fecal  masses,  and  is  apt  to  be  single.  Its  base  and 
edges  are  neither  prominent  nor  hard.  Syphilitic  ulcer  is  a 
tertiary  lesion  commonest  in  women.  There  are  numerous 
small  ulcers,  but  little  indurated,  with  sharp-cut  edges  which 
are  not  undermined.  These  ulcers  fuse  together  and  consti- 
tute one  large  irregular  ulcer ;  fibrous  tissue  forms  in  the 
wall  of  the  bowel,  induration  becomes  noticeable,  and  strict- 
ure follows.  There  is  profuse  discharge,  and  fistulse  are  apt 
to  form.  In  syphilis  there  may  be  a  breaking  down  of  a 
huge  gummy  mass.  Tubercular  ulceration  presents  a  conical 
ulcdrr  with  overhanging  edges  and  a  pale-red  base.  There 
is  some  mucous  discharge,  some  tenesmus,  and  a  little  pain. 
Dysentery,  catarrh,  neoplasms,  and  foreign  bodies  produce 
ulceration.  The  symptoms  are  constipation,  burning  pain 
on  defecation,  straining  at  stool,  and  blood  and  mucus  in 
the  stools.  The  diagnosis  is  made  by  digital  examination 
and  inspection  through  a  speculum. 

Treatment. — In  simple  ulcer  empty  the  bowel  by  the  ad- 
ministration of  a  saline  cathartic,  wash  out  the  rectum  with 
hot  water  after  the  saline  has  acted,  introduce  a  speculum, 
touch  the  ulcer  with  pure  carbolic  acid  or  silver  nitrate  (gr. 
xl  to  §j),  place  the  patient  in  bed,  restrict  him  to  a  liquid  diet, 
and  every  day  inject  iodoform  and  olive  oil  or  insufflate  iodo- 
form into  the  rectum.  If  this  fails,  give  ether,  stretch  the 
sphincter,  incise  the  ulcer  through  its  entire  thickness,  and 


DISEASES  AND  INJURIES  OF  THE  RECTUM  AND  ANUS.   719 

cauterize  with  fuming  nitric  acid,  caring  for  the  case  subse- 
quently as  we  would  a  patient  who  had  had  piles  ligated.  In 
tuboxular  ulcer  improve  the  general  health,  send  the  patient 
to  a  genial  climate,  or  at  least  into  the  sunlight  and  fresh  air, 
prevent  constipation,  give  nutritious  food,  especially  fats,  wash 
out  the  rectum  every  day  with  hot  water  and  insufflate  iodo- 
form or  inject  iodoform  emulsion.  Touch  the  ulcer  once  a 
week  with  silver  nitrate  (gr.  x  to  5J).  In  syphilitic  ulcer  give 
anti-syphilitic  treatment  and  treat  the  ulcer  locally  as  is  done 
in  tubercular  ulcer.  Dysoitcric  ulcer  requires  injections  of 
hot  water,  the  touching  of  the  ulcer  with  pure  carbolic  acid, 
and  insufflations  of  iodoform. 

Stricture  of  the  rectum  may  arise  from  s}'philitic 
tissue,  from  ordinary  inflammatory  tissue,  from  cicatrices 
of  operations,  from  sloughing,  from  tubercular  or  dysen- 
teric ulceration,  and  from  cancer.  The  usual  seat  of  simple 
stricture  is  from  one  inch  to  one  and  a  half  inches  above 
the  anus.  The  deposit  may  be  limited  to  the  submucous 
coat,  or  all  the  coats  may  be  involved.  A  syphilitic  lesion 
or  a  tubercular  lesion  may  cause  rectal  stricture ;  but  in 
some  cases  such  lesions  simply  open  the  tissues  to  the  in- 
fection, and  a  benign  rectal  stenosis  results. 

The  symptoms  of  rectal  stricture  are  constipation,  pain 
on  defecation,  straining  at  stool,  the  presence  of  blood  and 
mucus  in  the  stools,  an  open, anus,  and  the  passage  of  stools 
flattened  out  into  ribbons.  The  stricture  is  found  by  the  fin- 
ger or  by  the  bougie.  In  syphilitic  cases,  tubercular  cases, 
and  in  benign  cases,  the  fibrous  thickening  is  in  the  submu- 
cous coat,  and  in  syphilitic  and  tubercular  cases  the  mucous 
membrane  is  ulcerated.  Complete  obstruction  may  come  on, 
and  distended  abdomen  with  colic  is  very  usual. 

The  treatment  is  rest,  non-stimulating  diet,  warm-water 
injections,  mild  laxatives,  and  hot  hip-baths.  Cocain  sup- 
positories may  be  needed.  Any  existing  disease  is  treated. 
Bougies  are  passed  every  other  day.  Use  a  soft-rubber 
bougie,  warmed  and  oiled,  and  introduce  it  gently.  If  only 
the  method  of  gradual  dilatation  is  employed,  the  bougie 
must  be  used  always.  For  fibrous  strictures  forcible  dilatation 
(divulsion)  by  a  special  instrument  is  employed  or  incision 
is  practised.  Incision  (proctotomy)  may  be  either  external 
or  internal.  In  internal  proctotomy  one  or  more  incisions 
are  made  through  the  stricture  down  to  healthy  tissue,  the 
first  cut  being  in  the  middle  line  posteriorly.  External 
proctotomy,  which  divides  the  sphincters,  is  apt  to  leave 
incontinence  as  a  legacy.     Electrolysis    finds    some   advo- 


720  MODERN  SURGERY. 

cates,  but  on  what  grounds  it  is  difficult  to  see.  In  some 
cases  the  rectum  should  be  removed.  In  incurable  cases 
perform  inguinal  colostomy. 

Cancer  of  the  rectum  may  be  epithelioma,  but  it  is 
often  scirrhus.  It  not  unusually  occurs  before  the  thirty- 
fifth  year,  and  is  seen  as  early  as  the  twenty-fourth  year. 
The  retroperitoneal  and  inguinal  glands  are  involved  late  or 
not  at  all.  Extensive  ulceration  occurs.  A  hard  ring  is  apt 
to  encircle  the  rectum. 

Symptoms  and  Treatment. — The  symptoms  of  rectal 
cancer  are  like  those  of  simple  stricture,  except  that  the 
pain  is  greater,  the  hemorrhage  more  severe,  and  constipa- 
tion is  apt  to  alternate  with  diarrhea.  The  finger  and  the 
speculum  make  the  diagnosis.  In  rectal  cancer  metastasis 
occurs  late.  The  most  favorable  cases  for  operation  are 
those  in  which  the  growth  is  small  and  movable.  Accurately 
define  the  extent  of  the  growth  and  endeavor  to  make  out  if 
it  has  invaded  the  cellular  tissue  outside  of  the  rectum,  the 
prostate,  the  bladder,  the  sacrum,  the  uterus,  etc.  Cases  of 
widespread  invasion  should  not  be  subjected  to  radical  oper- 
ation. Palliative  treatment  is  as  follows  :  every  day  introduce 
a  tube  through  the  stricture,  wash  out  the  rectum  with  warm 
water,  and  after  washing  inject  emulsion  of  iodoform  (gr.  x  to 
§j  of  sweet  oil).  Injections  of  chlorid  of  zinc  (gr.  j  to  .Ij  of 
water)  lessen  the  foulness  of  the  discharge.  Eventually  co- 
lostomy is  performed.  This  operation  gives  great  comfort  to 
the  patient,  and  allays  pain  and  prolongs  life  by  intercepting 
the  feces  before  they  reach  the  cancer.  This  operation  is 
employed  for  inoperable  cancer,  for  obstruction,  and  in  cases 
where  metastasis  has  occurred.  Operative  treatment  includes 
one  of  several  procedures.  Internal  proctotomy  does  some 
good.  Excision  of  the  rectum  from  below  (Cripp's  oper- 
ation) is  practised  if  not  more  than  three  inches  require  re- 
moval, if  the  peritoneum  is  not  invaded,  and  if  the  adjacent 
organs  are  free  from  disease.  The  peritoneum  must  not  be 
opened  in  Cripp's  operation.  After  the  growth  is  removed 
the  divided  rectum  is  pulled  down  and  sutured  to  the  skin. 
Excision  of  the  rectum  after  excising  a  portion  of  the  sacrum 
(Kraske's  operation.  Fig.  249)  is  an  operation  which  permits 
removal  of  the  entire  tube,  portions  of  the  colon,  and  even  of 
adjacent  parts.  If  the  peritoneum  is  opened,  it  must  be  closed 
with  sutures.  The  lower  end  of  the  upper  segment  of  bowel 
is  fastened  in  the  wound.  The  upper  end  of  the  lower  seg- 
ment may  be  fastened  to  the  wound  or  closed.  Kraske's 
operation  may  be  done  by  an  osteoplastic  method,  the  bone 


DISEASES  AND  INJURIES  OF  THE  RECTUM  AND  ANUS.    72 1 

not  being  removed.  It  is  well  to  precede  a  Kraske  operation 
several  weeks  by  an  inguinal  colostomy,  which  permits  of 
cleansing  the  lower  bowel  from  feces  and  allows  the  sur- 
geon to  operate  with  a  fair  chance  of  escaping  infection. 
A  preliminary  colostomy  may  make  the  operation  of  extir- 
pation more  difficult  by  fixing  the  intestine,  and  thus  inter- 
fering with  the  necessary  drawing  down  of  the  gut  (E.  H. 


Fig.  249. — Different  levels  of  resection  of  the  sacrum:  KO,  Kocher's  line;  BA,  Kraske's  ; 
BH,  Hochenegg's  ;  BD,  Bardenheuer's  ;  RS,  Rose's  (Maas). 

Taylor).  If  the  growth  is  extensive  and  the  mesocolon  short, 
it  may  be  best  to  perform  a  right  inguinal  colostomy ;  but  in 
most  cases  left  inguinal  colostomy  is  preferred  (Gerster). 

Foreign  bodies  in  the  rectum,  if  small,  are  extracted 
with  forceps  and  the  fingers ;  if  large,  ether  must  first  be 
given  and  the  sphincter  must  be  dilated. 

Wounds  of  the  rectum  require  free  drainage,  antiseptic 
irrigation,  and  antiseptic  dressing. 

Ischiorectal  abscesses  are  situated  in  the  ischiorectal 
fossa.  They  travel  in  the  line  of  least  resistance,  which  is 
upward,  and  more  often  burst  into  the  bowel  than  externally. 
They  are  caused  by  cold,  by  external  traumatisms,  by  per- 
forations of  the  rectum  by  hard  fecal  masses,  or  by  the 
passage  of  bacteria  into  the  fossa  through  a  fissure,  an  ulcer, 
or  an  ulcerated  pile.  They  may  be  either  acute  or  tubercu- 
lar. The  symptoms  are  the  same  as  those  of  abscess  any- 
where, the  swelling,  however,  being  brawny  and  fluctuation 
being  hard  to  detect. 

The  treatment  is  instant  incision,  the  cut  radiating  from 

46 


722 


MODERN  SURGERY. 


the  anus  like  the  spoke  of  a  wheel.  Incision  is  followed  by 
irrigation  and  packing  with  iodoform  gauze  or  the  insertion 
of  a  drainage-tube. 

Imperforate  Anus. — There  are  two  forms  of  this  con- 
dition. In  one  form  the  rectum  empties  into  the  bladder, 
vagina,  or  urethra.  In  the  other  form  there  is  no  rectal 
opening  either  upon  the  surface  of  the  body  or  in  the  uri- 
nary organs.  The  diagnosis  is  usually  at  once  apparent, 
except  in  cases  where  the  anus  looks  normal,  when  the 
diagnosis  will  often  not  be  made  until  symptoms  of  obstruc- 
tion arise. 

Treatment. — If  the  rectum  bulges  when  the  child  cries, 
open  into  it  with  a  knife  and  keep  the  opening  patent  by 
inserting  a  plug  of  iodoform  gauze.  In  cases  in  which  the 
rectum  is  more  deeply  seated  a  catheter  is  introduced  into 
the  bladder,  an  incision  is  made  from  the  anus  to  the  coccyx, 
the  rectum  is  sought  for,  is  sewed  to  the  anus,  and  is  incised. 
In  some  cases  Keen  and  others  have  performed  Kraske's 
operation,  pulling  down  the  rectum  to  the  anal  margin, 
sewing  it  there,  and  incising  the  occluded  anus.  If  the  rec- 
tum cannot  be  found  or  cannot  be  pulled  down,  an  artificial 
anus  must  be  made. 

Vistula  in  ano  is  the  track  of  an  unhealed  abscess.  An 
abscess  in  the  anal  region  is  apt  to  refuse  to  heal  because  of 
the  constant  movement  of  the  parts  (produced  by  respiration, 
coughing,  the  passage  of  gas,  defecation,  etc.).  The  passage 
of  feces  will  keep  a  fistula  open.  If  a  tubercular  ulcer  per- 
forates, a  tubercular  sinus  forms,  and  a  tubercular  sinus  is  apt 
to  follow  a  cold  abscess  of  the  ischiorectal  space.  Fistula  is 
often  associated  with  phthisis  pulmonalis,  and  is  not  un- 
usually linked  with  piles,  cancer,   or  stricture. 

There  are  three  varieties  of  fistula — the  blind  external 
(Fig.  250,  a),  the  blind  internal  (Fig.  250,  b),  and  the  com- 
plete (Fig.  250,  c).  The  external  opening  is  usually  near  the 
anus,  but  may  be  far  away,  and  there  may  be  only  one  path- 


FiG.  250. — Fistula  in  ano  :  a,  blind  external ;  b,  blind  internal ;  c,  complete  (Esmarch  and 

Kowalzig). 


way  or  there  may  be  several  sinuses.    In  a  healthy  individual 
the  external  orifice  is  small  and  a  mass  of  granulations  sprouts 


DISEASES  AND  INJURIES  OF  THE  RECTUM  AND  ANUS.   723 

from  it.  In  tubercular  fistula  the  external  orifice  is  large 
and  irregular,  with  thin  and  undermined  edges,  shows  no 
granulations,  extrudes  small  quantities  of  sanious  pus,  and 
the  skin  about  it  is  purple  and  congested.  In  a  fistula  fol- 
lowing an  anal  abscess  the  internal  opening  is  just  above  the 
anus,  between  the  two  sphincters.  In  fistula  following  an 
ischiorectal  abscess  the  internal  opening  may  be  above  the 
internal  sphincter.  In  an  old  fistula  the  track  becomes 
fibrous  and  cannot  collapse.  The  synipto^ns  of  fistula  are  the 
passage  of  feces  and  gas  through  the  opening  and  the  flow 
of  a  discharge  which  stains  the  clothing.  In  a  complete 
fistula  a  probe  can  be  carried  from  the  external  opening  into 
the  bowel.  After  a  time  incontinence  of  feces  is  apt  to  come 
on,  repeated  attacks  of  inflammation  thickening  the  rectum 
and  destroying  its  sensibility.  From  time  to  time  the  open- 
ing will  block,  and  new  abscesses  form.  In  examining  a 
fistula  use  Brodie's  probe,  as  its  flat  handle  enables  one  to 
locate  the  direction  the  bent  instrument  has  taken,  and  its 
slender  shaft  will  find  its  way  through  a  very  small  channel. 
Treatment. — In  treating  a  fistula  cleanse  the  parts,  as 
cleanly  work,  though  it  will  not  prevent  pus,  will  limit  sup- 
puration. The  external  parts  are  washed  with  soap  and 
water.  The  rectum,  which  must  be  empty,  is  irrigated  with 
hot  saline  solution.  Corrosive  sublimate  should  not  be  used 
in  the  rectum,  because  it  is  irritant,  causes  a  flow  of  serum, 
and  hence  lessens  tissue-resistance,  and  is  rendered  inert  as  an 
antiseptic  by  being  converted  into  sulphid  of  mercury.  Anes- 
thetize the  patient.  Pass  a  grooved  director  through  the  sinus, 
bring  its  point  out  externally,  and  lift  the  tissues  between 
the  sinus  and  the  surface.  Incise  the  tissues  (Fig.  251). 
Push  the  finger  to  the  depth  of  the  wound, 
to  determine  that  the  sinus  does  not 
ascend  above  the  internal  opening.  Look 
for  branching  sinuses,  and  if  any  are  found, 
slit  them  open.  Curet  all  sinuses,  and  if 
they  are  very  fibrous,  clip  them  away  with 
scissors.  Cut  aw^ay  diseased  skin ;  irri- 
gate with  salt  solution  ;  pack  with  iodo- 
form gauze ;  and  dress  with  gauze  and 
a  T-bandage.  In  forty-eight  hours  re- 
move   the    dressings,    irrigate    w^ith    per-     ^  f"'^-    251  —Operation 

11  -It  fistula    in    ano   (bs- 

oxid    of    hydrogen    and    then    with    salt     march  and  Kowaizig). 
solution,  dust  with  iodoform,  insert  lightly 
to   the   depths   of  the  wound   a  piece  of   iodoform    gauze, 
and  reapply  the   dressings.      Dress  the  wound  thus  every 


724  MODERN  SURGERY. 

day  until  healing  is  almost  complete.  It  is  unnecessary  to 
confine  the  bowels  beyond  forty-eight  hours,  at  which  period, 
if  they  have  not  moved,  an  enema  is  given.  If  the  dressing 
at  any  time  becomes  stained  with  feces,  re-dress  at  once. 
Get  the  patient  out  of  bed  as  soon  as  possible.  Cut  the 
sphincter  at  a  right  angle  to  its  fibers,  and  do  not  cut  it  more 
than  once  at  one  operation.  If  there  are  two  fistulae,  cut 
one  through,  and  when  one  heals  cut  the  other.  In  some 
straight  sinuses  the  tract  can  be  extirpated  and  the  parts 
sutured,  primary  union  occasionally  resulting.  If  fecal  in- 
continence results  from  an  operation  for  fistula,  remove  the 
scar  tissue  and  endeavor  to  suture  the  separated  muscular 
fibers.  Should  an  operation  be  undertaken  if  phthisis  exists  ? 
Many  of  the  old  masters  said  no.  Matthews  sums  up  the 
modern  view :  in  incipient  phthisis  operate ;  in  rapidly  pro- 
gressive fistula  operate  whether  cough  exists  or  not ;  if  much 
cough  exists,  do  not  operate  unless  the  fistula  is  rapidly  pro- 
gressive ;  in  the  last  stages  of  phthisis  do  not  operate. 

Pruritus  of  the  anus  is  a  symptom,  and  not  a  disease. 
It  may  be  due  to  piles,  fissure,  seat-worms,  eczema,  nerve- 
disturbance,  kidney  disease,  jaundice,  constipation,  inebriety, 
opium-habit,  torpid  Hver,  dyspepsia,  alcohol,  tea-drinking, 
vesical  calculus,  smoking,  urethral  stricture,  uterine  dis- 
ease, diabetes,  ovarian  trouble,  and  mental  disorder.  The 
itching  is  worse  at  night,  and  is  often  of  fearful  intensity. 

Treatment. — Remove  the  cause.  Prevent  constipation. 
Further,  several  times  a  day,  wash  the  parts  with  very  hot 
water,  dry  them,  and  apply  a  mixture  containing  3j  of  cam- 
pho-phenique  and  5J  of  water  (Matthews).  Matthews  com- 
mends the  following  mixture  :  chloral,  3j ;  gum-camphor, 
3ss  ;  glycerin  and  water,  each  fj.^  In  this  disease  a  "  scarf- 
skin  "  forms,  which  must  be  made  to  peel  off  by  iodin,  pure 
carbolic  acid,  corrosive  sublimate  (grs.  iv  to  Ij  of  cosmolin), 
calomel  (^ij  to  5j  of  cosmolin),  or  campho-phenique.  In 
obstinate  cases  paint  the  parts,  night  and  morning,  with  a 
mixture  of  60  grs.  of  alum,  30  grs.  of  calomel,  and  300  grs. 
of  glycerin,  or  smear  with  an  ointment  composed  of  \  of  a 
part  of  oleate  of  cocain,  3  parts  of  lanolin,  2  parts  of  vaselin, 
and  2  parts  of  olive  oil  (Morain).  In  very  severe  cases 
touch  with  a  solution  of  silver  nitrate  (i  :  10)  or  employ  the 
Paquelin  cautery. 

Fissure  of  the  anus  is  an  irritable  ulcer  at  the  anal  ori- 
fice producing  spasm  of  the  sphincter.  Pain  exists  because 
of  twigs  of  nerves  upon  the  floor  of  the  crack.     Fissure  is 

1  Diseases  of  the  Rectum. 


ANESTHESIA   AND  ANESTHETICS.  725 

caused  by  constipation  or  traumatism.  The  symptom  is 
violent,  burning  pain,  sometimes  beginning  during  defecation, 
but  usually  at  the  end  of  the  act,  and  lasting  for  some  hours. 
Constipation  exists,  and  often  pruritus.  Examination  dis- 
closes a  fissure,  usually  at  the  posterior  margin,  running  up 
the  bowel  one-quarter  to  one-half  an  inch.  Piles  often  exist 
with  fissure. 

Treatment. — The  palliative  treatment  is  to  prevent  con- 
stipation, to  wash  out  the  rectum  with  cold  water,  and  apply 
an  ointment  made  by  evaporating  .^ij  of  the  juice  of  conium 
to  .oij  and  adding  it  to  .sj  of  lanolin  and  gr.  xij  of  persul- 
phate of  iron.  Pure  ichthyol  may  do  good.  In  operative 
treatment  stretch  the  sphincter.  In  order  to  stretch  the 
sphincter  the  patient  is  to  be  anesthetized,  the  surgeon's 
thumbs  are  inserted  into  the  rectum,  and  the  parts  are 
stretched  until  the  thumbs  touch  the  ischia.  After  stretch- 
ing the  sphincter  incise  the  floor  of  the  fissure,  scrape  it  with 
a  curet,  and  touch  with  nitrate  of  silver  stick. 

XXIX.  ANESTHESIA  AND  ANESTHETICS. 

Anesthesia  is  a  condition  of  insensibility  or  loss  of  feel- 
ing artificially  produced.  An  anesthetic  is  an  agent  which 
produces  insensibility  or  loss  of  feeling.  Anesthetics  are 
divided  into — (i)  General  anesthetics,  as  amylene,  chloroform, 
ethylene  chlorid,  ether,  bromid  of  ethyl,  nitrous  oxid,  and 
bichlorid  of  methylene  ;  (2)  Local  anesthetics,  as  alcohol, 
bisulphid  of  carbon,  chlorid  of  ethyl,  carbolic  acid,  ether 
spray,  cocain,  ice  and  salt,  and  rhigolene  spray. 

General  anesthesia  may  be  induced  to  abolish  the  usual 
pain  of  labor  and  of  surgical  procedures  ;  to  produce  mus- 
cular relaxation  in  hernia;,  dislocations,  and  fractures  ;  and 
to  aid  in  diagnosticating  abdominal  tumors,  joint-diseases, 
fractures,  and  malingering. 

Heart  disease  is  not  a  positive  contraindication  to  surgical 
anesthesia.  It  is  quite  true  that  anesthetics  are  dangerous 
in  people  with  fatty  hearts,  but  shock  is  equally  dangerous, 
and  the  surgeon  stands  between  the  Scylla  of  anesthesia 
and  the  Charybdis  of  shock.  Whenever  possible,  prepare 
a  patient  for  anesthesia.  Always  examine  the  urine  if  the 
nature  of  the  case  allows  time.  If  albumin  exists,  operation 
is  not  contraindicated  ;  but  the  peril  of  anesthesia  is  greater, 
and  certain  dangers  are  to  be  watched  for  and  guarded 
against.  If  much  albumin  is  present,  postpone  operation 
except  in  emergency  cases.    If  much  sugar  exists,  the  danger 


726  MODERN  SURGERY. 

is  considerable,  as  diabetic  coma  occasionally  develops.  Give 
a  purgative  the  night  before  giving  the  anesthetic.  In  the 
morning  allow  no  breakfast  if  the  operation  is  to  be  per- 
formed at  an  early  hour ;  but  if  the  patient  is  very  weak, 
order  a  little  brandy  and  beef-tea.  If  the  operation  is  to 
be  about  noon,  give  a  breakfast  of  some  beef-tea  and  toast 
or  a  little  consomme ;  ?ievcr  give  any  food  within  three 
hours  of  the  operation,  but  brandy  is  admissible  if  it  is 
required.  If  the  stomach  is  not  empty  at  the  time  of 
operation,  vomiting  is  almost  inevitable  and  portions  of 
food  may  enter  the  windpipe ;  if  the  stomach  contains  no 
food,  vomiting  is  far  less  likely  to  happen,  and  even  if  it 
occurs  and  vomited  matter  should  enter  the  windpipe  it  will 
do  little  harm,  as  it  consists  chiefly  of  Hquid  mucus.  In 
cases  of  intestinal  obstruction  in  which  there  has  been  ster- 
coraceous  vomiting,  there  is  much  danger  that  vomiting  will 
occur  during  anesthetization.  Vomiting  of  this  sort  is  pro- 
fuse, sudden,  and  dangerous.  It  may  flood  the  bronchial  tubes 
and  cause  death  by  suffocation.  In  such  a  case  wash  out  the 
stomach  before  giving  the  ether.  Vomiting  is  dangerous  also 
because  of  the  great  cardiac  weakness  which  precedes  'and 
follows  it.  Before  giving  the  anesthetic  see  that  artificial 
teeth  are  removed  and  that  the  patient  does  not  have  a  piece 
of  candy  or  a  chew  of  tobacco  in  the  mouth.  Always  have 
a  third  party  present  as  a  witness,  because  in  an  anesthetic 
sleep  vivid  dreams  often  occur,  and  erotic  dreams  in  women 
may  lead  to  damaging  accusations  against  the  surgeon.  Place 
the  patient  recumbent,  and  see  that  the  clothing  is  loose,  par- 
ticularly that  there  is  no  constriction  about  the  neck  and 
abdomen.  Do  not  have  the  head  high  unless  this  position  is 
demanded  by  the  exigencies  of  the  operation.  The  anesthe- 
tizer  must  have  a  mouth-gag,  a  pair  of  tongue-forceps,  a  hy- 
podermatic needle  in  working  order,  and  solutions  of  strych- 
nin, atropin,  digitalis,  and  brandy.  It  is  always  well  to  have 
an  electric  battery  and  a  can  of  oxygen  at  hand.  Accidents, 
it  is  true,  are  rare,  but  they  may  happen  at  any  time,  and 
hence  the  surgeon  should  always  be  prepared  for  them.  Any 
danger  which  arises  must  be  met  with  promptness  and  decis- 
ion, or  action  will  be  of  no  avail.  Many  surgeons  give  a 
hypodermatic  injection  of  morphin  a  short  time  before  opera- 
tion, to  steady  the  heart,  prevent  vomiting,  and  aid  the  bring- 
ing about  of  insensibihty  with  very  little  of  the  anesthetic. 

The  two  favorite  anesthetics  are  ether  and  chloroform. 
Chloroform  is  more  dangerous  than  ether  in  general  cases, 
though  it  is  more  agreeable,  less  irritant  to  the  lungs  and 


ANESTHESIA   AND  ANESTHETICS.  J 27 

kidneys,  and  quicker  in  its  action.  Recovery  from  chloro- 
form is  quicker  and  quieter  than  that  from  ether,  but  chloro- 
form-vomiting lasts  longer  than  ether-vomiting.  Chloroform 
may  induce  sudden  and  even  fatal  syncope.  Hare's  experi- 
ments on  animals  indicate  that  chloroform  may  kill  by  re- 
spiratory failure  occurring  secondarily  to  failure  of  the  vaso- 
motor center ;  but  certain  it  is  that  clinically  the  danger  of 
chloroform  is  paralysis  of  the  heart,  and  this  condition  may 
come  on  so  rapidly  that  death  may  occur  almost  before  an 
attempt  can  be  made  to  save  life.  Berkley  Hill  has  proved 
that  most  chloroform-deaths  that  take  place  after  consider- 
able of  the  anesthetic  has  been  taken,  arise  from  paralytic 
distention  of  the  heart.  Sudden  death,  when  inhalations  of 
chloroform  have  just  commenced,  may  be  due  to  the  nasal 
reflex.  If  ether  kills,  it  does  so  through  the  respiration,  and 
not  the  heart,  and  there  is  usually  time  to  undertake  means 
of  resuscitation,  which  means  are  apt  to  be  successful.  Chloro- 
form is  to  be  preferred  to  ether  in  the  following  cases :  for 
children  under  ten  years  of  age,  in  whom  ether  causes  a  great 
outflow  of  bronchial  mucus,  which  may  asphyxiate ;  for  people 
over  sixty,  free  from  advanced  cardiac  disease,  at  which  age 
most  persons  have  some  bronchitis,  and  ether  chokes  them 
up  with  mucus.  Ether  also  irritates  the  kidneys,  which  at 
the  latter  age  are  apt  to  be  weak  or  diseased.  Chloroform  is 
preferred  for  labor  cases,  when  moderate  anesthesia  only  is 
required ;  and  for  operations  on  the  mouth  and  nose.  In 
cleft  palate  chloroform  should  always  be  used  to  limit  cough 
and  to  minimize  salivary  flow.  In  ligation  of  a  large  artery 
which  is  overlaid  by  a  vein,  ether  exercises  the  unfortunate 
influence  of  greatly  enlarging  the  vein.  Hence  in  such  a 
case  chloroform  makes  the  operation  easier.  In  goiter  oper- 
ations ether  should  not  be  used,  as  it  enlarges  enormously 
the  veins.  Chloroform  is  preferred  for  patients  with  difficult 
respiration  from  any  cause ;  for  patients  with  kidney  disease 
and  for  patients  with  diabetes.  Some  surgeons  do  not  use 
ether  in  abdominal  operations  because  they  believe  it  may 
cause  persistent  oozing  of  blood,  but  this  view  is  not  in 
accord  with  the  author's  experience.  Ether  is  safer  in 
patients  with  heart  disease,  and  is  the  best  and  safest  anes- 
thetic for  general  use.  Both  ether  and  chloroform  may 
induce  changes  in  the  blood.  In  many  cases  they  produce 
a  diminution  of  hemoglobin.  In  some  cases  they  produce 
alteration  in  the  shape  of  the  corpuscles.  This  is  especially 
true  in  anemic  blood.  Ether  produces  leukocytosis.  These 
blood-changes  indicate  that  prolonged  anesthesia  may  mili- 


728  MODERN  SURGERY. 

tate  against  recovery  from  a  severe  operation.  In  anesthesia 
the  temperature  drops  from  one  to  three  degrees,  hence 
the  patient  should  be  carefully  covered  during  the  oper- 
ation. The  question  as  to  the  effect  of  ether  on  the  kidneys 
is  much  disputed.  Most  surgeons  beHeve  that  it  tends  to 
cause  albuminuria  or  increase  existing  albuminuria;  others 
deny  this. 

Administration  of  Chloroform.  —  In  administering 
chloroform  have  at  hand  a  mouth-gag,  tongue-forceps,  a 
clean  towel,  a  hypodermatic  .syringe,  solutions  of  strychnin, 
atropin,  and  brandy,  an  electric  battery,  and  a  can  of  oxygen. 
Use  only  pure  chloroform  (Squibb's).  The  patient  must  be  re- 
cumbent. No  special  inhaler  is  required,  but  the  drug  may 
be  given  upon  a  thin  towel,  a  napkin,  or  a  piece  of  lint.  The 
inhaler  of  Esmarch  is  very  useful.  In  operations  about 
the  face  Souchon's  instrument  is  serviceable.  Souchon's 
apparatus  is  so  arranged  that  chloroform  may  be  given 
through  a  tube  which  is  introduced  through  the  nose,  the 
instrument  being  well  out  of  the  way  of  the  operator. 
Some  surgeons  cocainize  the  nares  before  giving  chloro- 
form, so  as  to  prevent  the  dangerous  nasal  reflex  (Rosenberg). 
The  chloroform-vapor  must  be  well  mixed  with  air.  The 
chloroform  is  sprinkled  on  the  fabric  with  a  drop-bottle.  Put 
the  napkin  well  above  the  mouth,  add  five  drops  of  chloro- 
form, and  tell  the  patient  to  take  deep  and  regular  breaths. 
Add  a  few  more  drops  of  chloroform,  and  when  the  patient 
grows  so  accustomed  to  it  as  not  to  choke,  turn  the  wet  part 
of  the  fabric  toward  the  face  and  place  it  near  the  mouth;  do 
not  touch  the  mouth  with  the  wet  lint,  because  it  will  blister. 
It  is  a  good  plan  to  smear  the  lips  with  cosmolin  to  prevent 
blistering.  If  the  drug  is  given  gradually,  struggling  is  not 
usually  violent  or  prolonged.  Never  pour  on  a  large  amount 
at  one  time.  During  the  stage  of  excitement  do  not  suspend 
the  administration  of  chloroform  unless  respiration  becomes 
difficult,  in  which  case  suspend  it  until  the  patient  takes  one 
or  two  respirations.  Chloroform-vapor  is  not  inflammable, 
hence  it  is  safer  than  ether  when  a  hot  iron  is  to  be  used 
about  the  face  and  when  there  is  a  lighted  lamp  or  a  stove 
in  a  small  room ;  but  the  presence  of  flame  decomposes 
chloroform  into  irritant  products  of  chlorin,  which  some- 
times cause  the  patient  and  the  surgeon  to  cough.  A  com- 
bination of  chloroform  and  oxygen  is  used  by  some  admin- 
istrators. The  patient  who  is  anesthetized  with  the  mixed 
vapor  retains  a  good  color,  but  it  requires  a  considerable 
time  to  render  him  unconscious. 


ANESTHESIA    AND   ANESTHETICS. 


729 


Fig.  252. — AUis's  ether-inhaler. 


Administration  of  Bther. — Ether  is  best  given  by 
means  of  an  Allis  inhaler  (Fig.  252).  Have  at  hand  the 
same  instruments  as  for  chloroform. 
Place  the  dry  inhaler  over  the 
mouth  and  nose,  let  the  patient 
take  several  breaths  to  gain  confi- 
dence, pour  a  few  drops  of  ether 
into  the  cone,  let  the  patient  take 
several  more  breaths,  and  so  on, 
gradually  increasing  the  amount  of 
ether.  Never  suddenly  add  a  large 
amount  of  the  anesthetic  :  it  causes 
coughing  and  often  vomiting.  When 
the  patient  becomes  thoroughly  an- 
esthetized, diminish  the  amount  of 
ether ;  when  bleeding  is  profuse,  do 
the  same.  If  a  hot  iron  is  to  be  used 
about  the  face,  take  away  the  cone 
and  fan  away  the  ether  before  bringing  the  iron  near.  Have 
any  light  set  high  up,  as  ether-vapor  is  heavier  than  air,  and 
no  explosion  is  possible  until  it  reaches  the  level  of  the  flame. 
If  the  vapor  takes  fire,  cover  the  patient's  mouth  and  nose 
with  a  towel.  The  use  of  oxygen  with  ether  delays  the  pro- 
duction of  unconsciousness. 

Anesthetic  State  from  Bther  or  Chloroform. — The 
inhalation  of  an  anesthetic  produces  irritation  of  the  fauces, 
some  cough,  a  profuse  secretion  of  mucus,  acts  of  swallow- 
ing, dilatation  of  the  pupils,  flushed  face,  and  sometimes  strug- 
gling (especially  in  children  and  in  drunkards).  The  cough 
soon  ceases,  the  respirations  become  rapid  and  often  convul- 
sive, the  pulse  becomes  frequent,  and  the  patient  passes  into 
a  condition  of  active  intoxication  with  preservation  of  sight 
and  touch,  loss  of  hearing  and  smell,  diminution  of  pain  and 
sensibility,  and  often  with  illusions  or  hallucinations.  From 
this  state  many  subjects  (strong  men  and  drunkards)  pass 
into  a  stage  of  rigidity  in  which  the  muscles  become  rigidly 
fixed,  the  breathing  impeded,  the  respirations  stertorous,  and 
the  face  bluish  and  congested.  Too  rapid  forcing  of  the  an- 
esthetic tends  to  cause  rigidity,  and  a  skilled  anesthetizer  en- 
deavors to  avoid  its  production,  because  it  is  dangerous.  The 
next  stage  is  one  of  insensibility :  the  pupils  are  contracted, 
but  may  react  slightly  to  light;  the  conjunctival  reflex  is 
gone;  the  lids  are  closed;  if  the  arm  is  lifted  and  allowed  to 
fall,  it  drops  as  a  dead  weight ;  the  skin  is  cool  and  moist, 
and  often  wet  with  sweat ;  the  respirations  are  easy  and  shal- 


730  MODERN  SURGERY.       . 

low ;  the  pulse  is  slow ;  and  there  is  complete  unconscious- 
ness to  pain.  The  loss  of  the  conjunctival  reflex  is  the  usually- 
accepted  sign  that  the  patient  is  unconscious.  In  a  young  child 
this  reflex  is  soon  exhausted  by  touching  the  eye,  but  the 
sign  is  unreliable.  If  a  baby  is  to  be  anesthetized,  the  admin- 
istrator places  his  finger  in  the  infant's  hand.  The  child 
grasps  the  finger,  and  relaxes  its  grasp  when  unconscious. 
If  anesthesia  is  deep,  the  contracted  pupils  will  not  react  to 
light ;  if  anesthesia  is  profound,  the  pupils  dilate,  but  will  not 
react  to  light. 

Always  bear  in  mind  that  a  dilated  pupil  reacting  to  light 
and  associated  with  preserved  conjunctival  reflex  means  that 
anesthesia  is  not  complete ;  that  a  contracted  pupil  reacting 
to  light  and  without  conjunctival  reflex  means  moderate  an- 
esthesia ;  that  a  contracted  pupil  not  reacting  to  light  and 
without  conjunctival  reflex  means  deep  anesthesia;  that  a 
dilated  pupil  not  reacting  to  light  and  associated  Avith  lost 
conjunctival  reflex  means  dangerously  profound  anesthesia ; 
that  weak  pulse  and  pallor  may  be  due  to  nausea,  but  always 
require  instant  attention ;  that  vomiting  may  be  due  to  forcing 
strong  vapor  upon  the  patient,  but  that  it  may  also  be  due 
to  his  partially  emerging  from  a  state  of  insensibility. 

Watch  the  pulse  carefully  to  see  if  it  becomes  very  weak, 
irregular,  abnormally  slow,  or  abnormally  fast.  Syncope 
may  be  due  to  nausea,  shock,  hemorrhage,  or  the  giving  of 
too  much  of  the  drug.  Watch  the  respiration,  and  do  not 
forget  that  the  chest-walls  and  belly  may  move  when  no  air 
is  entering  the  lungs ;  hence  always  listen  to  the  breathing. 
Obstruction  of  the  air-passages  may  be  due  to  some  foreign 
matter,  as  blood  or  vomit,  lodging  in  the  bronchial  tubes,, 
windpipe,  larynx,  or  pharynx ;  to  falling  back  of  the  tongue 
(swallowing  of  the  tongue) ;  to  closure  of  the  epiglottis ;  or 
to  the  glottis  being  pushed  against  the  pharyngeal  wall  by 
bending  the  head  forward.  Some  patients  with  occluded 
nostrils  may  fail  to  get  enough  air  because  of  closure  of  the 
lips.  A  patient  may  appear  to  forget  to  breathe.  Shock  is 
manifested  by  deadly  pallor,  weak  and  irregular  pulse,  slow 
respiration,  cold  extremities,  and  a  drenching  sweat. 

Treatment  of  Complications. — In  rare  cases  edema  of 
the  lungs  occurs.  This  condition  is  treated  by  instant  vene- 
section, the  inhalation  of  nitrite  of  amyl,  and  the  administra- 
tion of  stimulants  and  nitroglycerin  hypodermatically.  Vomit- 
ing due  to  too  much  anesthetic  is  corrected  by  givmg  a  few 
breaths  of  air ;  vomiting  due  to  incomplete  anesthesia  is 
amended  by  giving  more  of  the  vapor.     When  the  patient 


ANESTHESIA   AND  ANESTHETICS.  73 1 

vomits,  hang  the  head  over  the  edge  of  the  bed,  separate 
the  jaws  with  the  gag,  and  wipe  out  the  vomited  matter, 
mucus,  and  sahva.  Shock  is  treated  by  diminishing  the 
amount  of  the  anesthetic  given,  by  the  hypodermatic  in- 
jection of  brandy,  strychnin,  or  atropin  (the  last-named 
drug  is  very  useful  when  there  is  a  profuse  sweat),  by  sur- 
rounding the  patient  with  hot-water  bottles,  or  by  wrapping 
him  in  hot  blankets  and  lowering  the  head  of  the  bed.  A 
tendency  to  syncope  requires  lowering  of  the  head  of  the 
bed,  suspension  of  the  anesthetic,  and  hypodermatic  injection 
of  strychnin.  In  extreme  syncope,  which  is  most  apt  to 
occur  from  chloroform,  do  not  wait  for  breathing  to  cease,  but 
suspend  the  anesthetic,  open  the  mouth  with  the  gag,  catch 
the  tongue  and  make  rhythmical  traction  while  an  assistant 
is  making  slow  artificial  respiration,  and  lower  the  head  of  the 
bed.  If  the  patient  does  not  at  once  improve,  invert  him  com- 
pletely, holding  him  by  the  legs  and  continuing  artificial 
respiration  by  compressing  the  sternum  (Nelaton).  By  con- 
tinuing artificial  respiration  the  blood  is  urged  on  through 
the  heart.  Berkley  Hill  holds  that  in  the  failure  which  arises 
soon  after  administration  of  chloroform  is  begun  the  trouble 
is  due  to  vasomotor  paralysis  with  starvation  of  the  nerve- 
centers.  In  such  a  case  he  applies  abdominal  compression 
and  inverts  the  patient,  making  artificial  respiration  at  the 
same  time.  In  the  failure  which  occurs  after  considerable 
chloroform  has  been  taken  there  are  paralytic  distention  of 
the  heart,  fulness  of  the  venous  system,  and  loss  of  the  com- 
pensations for  the  hydrostatic  effects  of  gravity.  In  such  a 
condition  empty  the  distended  heart  of  venous  blood  by 
raising  the  patient  into  an  erect  position ;  and  after  a  mo- 
ment place  him  recumbent  and  make  artificial  respiration. 
Give  hypodermatic  injections  of  ether,  brandy,  strychnin,  or 
even  of  ammonia.  Put  mustard  over  the  heart  and  spine. 
Employ  faradism  to  the  phrenic  nerve  (one  pole  to  the  epi- 
gastric region,  the  other  to  the  right  side  of  the  root  of  the 
neck).  Let  fresh  air  into  the  room,  put  hot-water  bottles 
around  the  legs,  apply  friction  to  the  extremities,  wrap  the 
patient  in  hot  blankets,  give  an  enema  of  brandy,  and  hold 
ammonia  or  nitrite  of  amyl  to  the  nose. 

"  Forgetting  to  breathe  "  is  met  by  removing  the  inhaler 
and  waiting  a  moment ;  a  breath  will  usually  be  taken  soon ; 
but  if  it  is  not  taken,  open  the  mouth  and  pull  forward  the 
tongue ;  this  causes  a  reflex  inspiration.  Obstrnction  to 
breathing  from  bending  forward  of  the  head  may  be  amended 
by  changing  the  position  of  the  head  or  by  pulling  forward 


732  MODERN  SURGERY. 

the  tongue.  Cyanosis,  if  slight,  is  met  by  removing  the  in- 
haler while  the  patient  takes  a  breath  or  two  of  air ;  but  if 
the  condition  grows  worse,  suspend  the  drug,  dash  cold  water 
in  the  face,  force  open  the  jaws,  pull  forward  the  tongue, 
make  artificial  respiration  until  a  breath  is  taken,  and  then  give 
oxygen  for  a  time.  If  these  means  fail,  stretch  the  sphincter 
ani  and  bleed  from  the  external  jugular  vein.  If  a  breath  is  not 
now  taken,  do  tracheotomy.  In  respiratory  or  heart  failure 
forced  artificial  respiration  by  Fell's  method  is  of  great  value. 
In  Fell's  method  a  tracheal  tube  is  inserted,  and  by  means  of 
a  foot-bellows  air  is  forced  into  the  lungs,  after  first  passing 
through  a  warming  chamber.  Wood  says,  instead  of  a  tra- 
cheal tube,  we  may  use  a  face-mask  and  an  intubation-tube. 
"  Swallowing  the  tongue  "  is  corrected  by  pulling  the  tongue 
forward.  If  it  tends  to  recur,  lay  the  head  upon  its  side  or 
keep  the  tongue  anchored  with  forceps.  Closure  of  the 
epiglottis  is  corrected  by  pulling  the  patient's  head  over 
the  edge  of  the  table  and  pushing  strongly  back  upon  his 
forehead.  This  maneuver  lifts  the  hyoid  bone,  and  with  it 
the  epiglottis.  The  epiglottis  can  be  lifted  by  passing  a 
spoon-handle  or  the  index  finger  over  the  dorsum  to  the 
base  of  the  tongue  and  pressing  forward.  If,  in  obstruction 
to  respiration,  the  above  means  fail,  make  artificial  respira- 
tion at  once ;  if  obstruction  continues,  perform  tracheotomy. 

After  stopping  the  anesthetic  in  an  ordinary  case,  have 
the  patient  carefully  watched  until  consciousness  and  intelli- 
gence are  entirely  restored.  The  face  is  washed  with  cold 
water  and  the  patient  is  kept  recumbent.  If  vomiting  occurs, 
his  head  is  hung  over  the  edge  of  the  bed  and  the  mouth  is 
subsequently  wiped  out.  Inhalation  of  the  vapor  of  vinegar 
is  of  great  service  in  post-anesthetic  vomiting  (Lewin,  Macken- 
rodt).  Draughts  of  liot  water  may  relieve  vomiting  by  wash- 
ing out  the  mucus  from  the  stomach.  Inhalation  of  oxygen 
rapidly  brings  a  patient  out  of  the  anesthetic  state,  and  aids 
in  the  arrest  of  vomiting.  Do  not  permit  a  person  to  take 
food  for  eight  hours  after  the  administration  of  an  anes- 
thetic. 

Primary  Anesthesia. — Instruct  the  patient  to  count  out 
aloud  and  hold  one  arm  above  his  head.  Give  the  ether 
rapidly.  In  a  short  time  he  becomes  mixed  in  his  count 
and  his  arm  sways  or  drops  to  the  side.  There  is  now  a  period 
of  insensibility  to  pain  lasting  only  about  half  a  minute,  and 
during  this  period  a  minor  operation  can  be  performed.  The 
patient  quickly  reacts  from  primary  anesthesia  without  vom- 
iting (Packard). 


ANESTHESIA   AND   ANESTIJETICS.  733 

Hthyl  bromid  is  sometimes  used  for  short  operations. 
The  unconsciousness  is  obtained  in  one-half  minute  and  is 
rapidly  recovered  from,  and  there  is  no  after-sickness.  The 
unconscious  lasts  about  three  minutes.  Three  drachms  are 
given  to  a  child,  and  six  drachms  to  an  adult.  A  towel  is 
put  over  the  face,  and  the  entire  amount  to  be  given  is  poured 
on  at  once,  and  as  soon  as  the  patient  is  unconscious  the 
towel  is  taken  away  and  no  more  of  the  drug  is  given 
(Cumston).  Cases  have  been  reported  in  which  sudden 
death  has  followed  the  administration  of  this  drug,  and  it 
should  not  be  given  if  there  is  disease  of  the  heart,  lungs,  or 
kidneys' 

Schleich  has  recently  introduced  a  new  anesthetic 
agent  which  he  claims  is  safer  than  chloroform.  This  sur- 
geon maintains  that  a  material  is  safe  as  an  anesthetic  only 
when  almost  all  of  the  amount  taken  in  at  an  inspiration 
is  expelled  on  expiration.  The  anesthetic  is  unsafe  in 
direct  proportion  to  the  amount  absorbed ;  and  the  lower 
the  boiling-point  of  an  anesthetic,  the  less  is  absorbed  ; 
hence  an  anesthetic  agent,  to  be  safe,  should  have  a  low 
boiling-point.  Schleich  makes  three  solutions.  The  first 
contains  (by  volume)  i^  oz.  of  chloroform,  \  oz.  of  petro- 
leum ether,  and  6  oz.  of  sulphuric  ether.  The  second  con- 
tains i^  oz.  of  chloroform,  \  oz.  of  petroleum  ether,  and  5 
oz.  of  sulphuric  ether.  The  third  contains  i  oz.  of  chloro- 
form, \  oz.  of  petroleum  ether,  and  2|-  oz.  of  sulphuric 
ether.  The  anesthetic  can  be  given  in  an  Esmarch  inhaler,  an 
Allis  inhaler,  or  a  towel.  Meyer  and  Maduro  have  tried  this 
method.  They  consider  these  solutions  safer  than  ether  or 
chloroform.  The  anesthetic  state  is  quiet,  reaction  is  rapid, 
and  vomiting  occurs  in  but  half  the  cases. 

Nitrous-oxid  Gas  may  be  used  to  obtain  anesthesia 
for  brief  operations.  It  is  sometimes  useful  to  anesthetize 
with  nitrous  oxid  and  maintain  the  unconsciousness  with 
ether.  In  a  more  prolonged  operation  nitrous  oxid  can  be 
given  mixed  with  oxygen.  This  gas  is  stored  in  steel 
cylinders,  in  which  it  is  liquified.  The  gas  is  passed  into  a 
rubber  bag,  and  is  given  to  the  patient  by  means  of  a  tube 
and  a  mouth-mask,  a  wedge  being  placed  between  the 
patient's  molar  teeth,  and  the  nostrils  being  closed  by  the 
anesthetizer's  fingers.  The  wedge  must  be  held  by  a  string 
so  that  it  cannot  be  swallowed.  The  patient  becomes  un- 
conscious in  about  one  minute,  and  we  know  the  patient  is 
anesthetized  by  the  stertor  and  cyanosis  and  the  insensitive- 

1  See  Cumston,  in  Boston  Med.  and  Surg.  Jour.,  Dec.  20,  1894. 


734 


MODERN  SURGERY. 


ness  of  the  conjunctiva.  Watch  the  pulse,  and  if  it  flags  at 
once  suspend  the  administration. 

I/OCal  Anesthesia. — Freezing  with  Ice  and  Salt. — 
Take  one-quarter  of  a  pound  of  ice,  wrap  it  in  a  towel,  and 
break  it  into  fine  bits  ;  add  one-eighth  of  a  pound  of  salt ; 
then  place  the  mixture  in  a  gauze  bag  and  lay  it  upon  the 
part.  The  surface  becomes  pallid  and  numb,  and  in  about 
fifteen  minutes  is  decidedly  analgesic.  A  spray  of  rhigolene 
freezes  in  about  ten  seconds.  It  is  highly  inflammable. 
Chlorid  of  ethyl  comes  in  glass  tubes.  Remove  the  cap 
from  the  tip  of  the  tube  and  hold  the  bulb  in  the  palm :  the 
warmth  of  the  hand  causes  the  fluid  to  spray  out.  Hold  the 
tube  some  little  distance  from  the  part  and  let  the  fine  spray 
strike  the  surface.  The  skin  blanches  and  whitens,  and  is 
ready  for  the  operation  in  about  thirty  seconds.  Ether-spray 
anesthesia  was  suggested  by  Benjamin  Ward  Richardson. 

Cocain  Hydro  chlorate. — Always  bear  in  mind  that  cocain 
is  sometimes  a  decidedly  dangerous  agent.  There  are  on  rec- 
ord fourteen  deaths  from  cocain  (Reclus).  Never  use  over 
two-thirds  of  a  grain  upon  a  mucous  surface,  and  never  in- 
ject hypodermatically  more  than  one-third  of  a  grain.  The 
urethra  is  a  particularly  dangerous  region,  and  so  is  the 
face.  Mild  cases  of  cocain-poisoning  are  characterized  by 
great  tremor,  restlessness,  pallor,  dry  mouth,  talkativeness, 
and  weak  pulse.  In  severe  cases  there  is  syncope  or  de- 
lirium. Death  may  arise  from  paralysis  or  from  fixation 
of  the  respiratory  muscles  (Mosso).  Cases  with  a  tendency 
to  respiratory  failure  require  the  hypodermatic  injection 
of  strychnin.  In  cases  with  tetanic  rigidity  of  muscles 
give  enemata  of  chloral,  hypodermatic  injections  of  nitro- 
glycerin, or  inhalations  of  the  nitrite  of  amyl.  In  cases 
marked  by  delirium,  if  the  circulation  is  good,  give  chloral 
or  hyoscin.  In  any  case  give  stimulants,  employ  a  catheter, 
and  favor  diuresis.  Cocain-poisoning  is  always  followed  by 
a  wakeful  night.  Cocain  should  not  be  used  if  the  kidneys 
are  inefficient.  In  using  cocain  try  to  prevent  poisoning. 
Have  the  patient  recumbent.  One  minute  before  giving  the 
cocain  administer  one  drop  of  a  i  per  cent,  alcoholic  solu- 
tion of  trinitrin,  repeating  the  dose  once  or  twice  during  the 
operation.  In  operation  on  a  finger,  after  making  the  part 
anemic  tie  a  tube  around  the  root  of  the  digit  before  inject- 
ing cocain,  and  after  the  operation  gradually  loosen  the  tube. 
A  hot  solution  of  cocain  is  more  efficient  than  a  cold  solu- 
tion (T.  Costa) ;  hence  hot  solutions  can  be  used  in  much 
less  strength  and  are  safer.     Merck  prepares  a  safer  agent 


ANESTHESIA  AND  ANESTHETICS.  735 

than  the  hydrochlorate,  and  that  is,  the  phenate  of  cocain. 
This  is  a  honey-Hke  material,  soluble  in  alcohol.  It  is  used 
locally  in  from  5  to  10  per  cent,  solutions.  It  takes  longer 
to  act  than  does  the  hydrochlorate,  and  it  coagulates  the 
tissue-albumin,  and  thus  absorption  is  lessened.  It  causes 
anemia  and  anesthesia,  and  retards  germ-growth  (Kyle), 
Gliick  and  Bartholovv  some  time  ago  advised  a  mixture  com- 
posed of  cocain  hydrochlorate  and  carbolic  acid. 

Eucain  hydrochlorate  is  far  safer  than  cocain,  and  in 
most  cases  is  to  be  preferred  to  it.  It  is  used  in  the  strength 
of  from  2  to  5  per  cent.  It  can  be  boiled  without  destroying 
its  properties,  and  hence  can  be  readily  rendered  sterile.  Un- 
fortunately, it  occasionally  happens  that  the  injection  of  eucain 
causes  sloughing,  especially  at  the  extremities,  in  fatty  tissue, 
in  tendon-sheaths,  and  in  bursae. 

Infiltration-anesthesia  was  devised  by  Schleich  of  Leipsic, 
who  was  dissatisfied  with  cocain,  because  it  is  not  safe  and 
sometimes  fails  to  produce  satisfactory  anesthesia  owing  to 
want  of  thorough  diffusion.  He  found  that  salt  solution 
(^  per  cent.),  if  injected  into  uninflamed  parts,  produced 
anesthesia.  To  obtain  this  anesthesia  the  part  must  be  dis- 
tended by  wide  infiltration.  If  minute  quantities  of  cocain, 
morphin,  and  carbolic  acid  are  added  to  the  solution,  the 
anesthesia  becomes  more  thorough  and  more  prolonged, 
and  can  be  obtained  even  in  inflamed  areas. 

Schleich  uses  three  solutions  : 

No.  I,  a  strong  solution,  which  is  used  in  inflamed  areas  : 
cocain  hydrochlorate,  0.20  gm. ;  morphin  hydrochlorate, 
0.025  gm. ;  sodium  chlorid,  0.20  gm. ;  distilled  water,  100 
gm. ;  phenol  (5  per  cent),  2  drops. 

No.  2,  a  medium  solution,  which  is  employed  in  most 
cases:  cocain  hydrochlorate,  o.  10  gm. ;  morphin  hydro- 
chlorate, 0.025  gm. ;  sodium  chlorid,  0.20  gm. ;  distilled 
water,    100  gm. ;  phenol  (5   per  cent.),   2  drops. 

No.  3  is  used  for  extensive  operations :  cocain  hydro- 
chlorate, 0.0 1  gm. ;  morphin  hydrochlorate,  0.005  g"^- 1  so- 
dium chlorid,  0.20  gm. ;  distilled  water,  100  gm. ;  phenol  (5 
per  cent.),   2  drops. 

The  injections  are  begun  in  the  skin,  not  imdci'  it  (Fig. 
253),  and  are  made  one  after  another  until  the  area  to  be 
operated  upon  is  surrounded  above,  below,  and  on  all  sides 
with  Schleich's  solution.  This  infiltration  can  be  made  pain- 
lessly by  touching  with  pure  carbolic  acid  the  point  where 
the  needle  is  to  be  inserted,  or  by  freezing  this  area  with  ethyl 
chlorid.    When  deeper  tissues  are  reached  they  are  infiltrated 


736  MODERN  SURGERY. 

before  incising  them.  If  a  nerve  comes  in  sight,  touch  it  with 
a  drop  of  pure  carbolic  acid  (Lund).  Schleich's  fluid  is  more 
efficient  when  cold.^  Van  Hook  says  that  the  anesthesia  ob- 
tained by  this  method  is  due  to  artificial  ischemia,  pressure 


Fig.  253. — The  syringe-point  stops  at  the  papillary  layer,  and  the  fluid  lodges  in  the  skin 
itself  (Van  Hook). 

upon  the  tissues,  the  direct  action  of  the  drugs,  and  the  low- 
ered temperature.^  The  method  is  very  efficient  and  can  be 
used  for  operations  of  considerable  magnitude. 


XXX,  BURNS  AND  SCALDS. 

Burns  and  scalds  are  injuries  due  to  the  action  of  caloric. 
Scalds  are  due  to  heated  fluids  or  vapors.  There  is  no  true 
pathological  difference  between  burns  and  scalds.  Dupuy- 
tren  classifies  burns  into  six  degrees,  as  follows  :  (i)  charac- 
terized by  erythema;  (2)  characterized  by  dermatitis  with  the 
formation  of  vesicles  ;  (3)  characterized  by  partial  destruction 
of  the  skin,  which  structure  is  not,  however,  entirely  burnt 
through  ;  (4)  characterized  by  destruction  of  the  skin  to  the 
subcutaneous  tissue;  (5)  characterized  by  destruction  of  all 
superficial  structures  and  of  part  of  the  muscular  layer ; 
(6)  characterized  by  "  carbonization  "  of  the  whole  thickness 
of  the  muscles. 

The  symptoms  are  local  and  constitutional.  Local  symp- 
toms are  pain  and  inflammation,  which  vary  in  nature,  in 
intensity,  or  in  degree  according  to  the  extent  of  tissue- 
damage.  Constitutional  symptoms  are  shock,  followed  by  a 
severe  reactionary  fever,  with  a  strong  tendency  to  conges- 
tion of  internal  parts.  The  constitutional  symptoms  which 
follow  a  severe  burn  are  due  in  part  to  the  absorption  of 
toxic  materials  from  the  seat  of  injury,  these  materials  hav- 

1  Lund,  Boston  Med.  and  Surg.  Jour.,  Feb.  6,  1896. 

2  Med.  News,  Nov.  i6,  1895. 


BURXS  AXD   SCALDS.  737 

ing  been  formed  by  the  action  of  heat  on  the  body-cells  and 
fluids.  Sepsis  is  not  infrequent.  The  stages  are  often  desig- 
nated as  prostration,  reaction,  and  suppuration.  Death  may 
be  due  to  shock,  to  sepsis,  to  exhaustion,  to  congestion  of 
the  brain,  lungs,  or  kidneys,  or  to  Curling's  ulcer  of  the 
duodenum. 

Treatment. — The  local  treatment  of  slight  burns  (as  sun- 
burn) is  to  moisten  the  parts  frequently  with  a  saturated  solu- 
tion of  bicarbonate  of  sodium,  a  solution  of  citrate  of  lime, 
or  a  I  :  8  solution  of  phenol  sodique.  In  burns  of  moderate 
degree  a  mixture  of  zinc  ointment  with  iodoform,  though 
not  antiseptic,  is  a  comfortable  dressing.  The  author  has 
been  using  normal  salt  solution  for  a  number  of  years,  and 
likes  it  very  much.  Some  surgeons  use  a  saturated  solution 
of  picric  acid.  Carron  oil  consists  of  equal  parts  of  linseed 
oil  and  lime-water.  It  allays  the  pain  of  a  burn,  but  it  is  a 
filthy  preparation,  and  its  use  is  followed  by  much  pus-for- 
mation. Cosmolin  gives  comfort  as  a  dressing,  but  should 
not  be  used  on  the  face,  lest  it  cause  pigmentation.  The  elder 
Gross  used  lead  paint.  A  solution  of  nitrate  of  potassium 
allays  the  pain.  In  a  severe  burn  cut  away  the  clothing, 
avoid  exposure  to  cold,  wash  the  part  with  a  solution  of 
peroxid  of  hydrogen  and  then  with  a  warm  solution  of 
boric  acid,  open  the  vesicles  with  an  aseptic  needle,  dust 
with  iodoform,  and  dress  with  aseptic  cotton,  or  else  dress 
with  lint  soaked  in  salt  solution.  Aseptic  dressing  of  a  burn 
is  often  painful,  and  may  demand  the  use  of  an  anesthetic. 
Change  the  dressings  no  oftener  than  is  required,  and  at 
each  change  wash  the  burn  with  peroxid  of  hydrogen  and 
boric  acid,  take  away  sloughs,  and  reapply  iodoform  and 
cotton  or  salt  solution.  Where  extensive  destruction  of 
tissue  has  taken  place  use  splints  and  extension  to  limit  con- 
tractures, and  skin-graft  as  soon  as  possible.  If  granulation 
is  slow,  stimulate  with  copper-sulphate  or  mild  silver-nitrate 
solutions.  Exuberant  granulations  require  burning  down. 
Flabby  granulations  require  pressure.  If  healing  is  slow,  or 
if  the  burn  is  extensive,  skin  graft.  When  an  extremity  has 
been  carbonized  amputation  must  be  performed.  In  constitu- 
tional treatnient\ix\\\o  about  reaction ;  combat  pain  with  opium ; 
and  keep  the  bowels  and  kidneys  active.  If  suppuration 
occurs,  give  tonics,  stimulants,  and  concentrated  foods. 
Complications  are  treated  according  to  general  rules. 

Scalds  of  the  glottis  are  due  to  the  inhalation  of  steam 
or  of  ignited  gas.  A  child  may  scald  the  glottis  by  trying 
to  drink  from  the  spout  of  a  kettle  (Moullin).     The  symp- 

47 


738  MODERN  SURGERY. 

toms  are  pain,  dysphagia,  and  dyspnea.  Edema  of  the 
glottis  comes  on  quickly.  The  treatment  is  tracheotomy  or 
intubation  of  the  larynx  in  severe  cases ;  in  mild  cases,  scari- 
fication of  the  larynx. 

Kflfects  of  Cold. — Local  Effects. — Cold  produces  numb- 
ness, pricking,  a  feeling  of  weight,  redness  of  the  surface 
followed  by  stiffness,  local  insensibility,  and  mottling  or  pal- 
lor. Sudden  intense  cold  causes  the  formation  of  blebs,  the 
coagulation  of  blood  in  the  superficial  veins,  and  violent 
pain  in  the  limb.  Cold  locally  produces  frost-bite  (page  128). 
The  constitutional  effects  of  cold  are  at  first  stimulating,  then 
depressing,  and  are  exhibited  by  uneasiness,  pain,  and  an 
intense  drowsiness  which,  if  yielded  to,  is  the  road  to  death 
by  way  of  internal  congestion.  Death  from  prolonged  cold 
resembles  in  appearance  death  from  apoplexy.  Death  from 
sudden  and  overwhelming  cold  is  caused  by  anemia  of  the 
brain  from  Aveak  circulation  and  capillary  embolism.  To 
bring  a  partly-frozen  person  into  a  warm  room  may  cause 
death  by  embolism. 

Treatment. — Frost-bite  is  treated  as  outHned  on  page  128. 
When  a  person  is  nearly  frozen  to  death  place  him  in  a  cool 
room,  but  under  no  circumstance  in  a  cold  bath,  make  arti- 
ficial respiration,  rub  him  down  with  flannel  soaked  in  alcohol 
or  in  whiskey,  and  follow  this  by  rubbing  with  dry  hands. 
After  a  time  wrap  the  patient  in  warm  blankets  and  give  an 
enema  of  brandy.  Mustard  plasters  are  to  be  appHed  over 
the  heart  and  spine.  As  soon  as  swallowing  is  possible 
brandy  is  administered  by  the  mouth.  As  the  condition 
improves  gradually  raise  the  temperature  of  the  room  and 
give  Jiot  drinks. 

Chilblain,  or  pernio,  is  the  secondary  effect  of  cold.  It 
usually  appears  as  a  local  congestion  upon  the  toes,  the 
fingers,  or  the  nose,  and  it  is  apt  now  and  then  to  inflame 
and  ulcerate.  A  chilblain  is  apt  to  become  congested  by 
approaching  a  fire  or  by  taking  exercise,  and  when  con- 
gested it  itches,  tingles,  and  stings.  Frequent  attacks  of 
congestion  produce  crops  of  vesicles ;  these  vesicles  rupture 
and  expose  an  ulcer,  which  in  rare  instances  sloughs. 

Treatment. — Prevent  congestion  of  the  legs  and  feet  if 
chilblain  affects  the  toes.  Order  large  shoes  and  woollen 
stockings  and  forbid  tight  garters.  The  patient  with  pernio 
must  take  regular  outdoor  exercise  and  must  not  loiter 
around  a  hot  fire.  Every  morning  and  evening  he  should 
take  a  general  cold  sponge-bath,  following  by  rubbing  with 
alcohol  and  frictions  with  a  coarse  towel,  and  he  should 


DISEASES   OF   THE   SKIN  AND   NAILS.  739 

sleep  with  warm  stockings  on  or  with  his  feet  upon  a  hot- 
water  bag.  When  a  chilblain  is  only  a  congested  spot  it 
should  be  washed  twice  a  day  in  cold  salt  water,  rubbed  dry 
with  flannel,  and  subjected  to  applications  of  tincture  of 
iodin  and  soap  liniment  (i  :  2),  tincture  of  cantharides  and 
soap  liniment  (i  :  6),  or  equal  parts  of  turpentine  and  olive 
oil  (W.  H.  A.  Jacobson).  Jacobson  says  itching  is  relieved 
by  painting  belladonna  liniment  upon  the  part  and  allowing 
it  to  dry.  If  vesicles  form,  paint  with  contractile  collodion  ; 
if  ulcers  form,  dress  antiseptically.  If  ulcers  are  sluggish, 
use  equal  parts  of  resin  cerate  and  spirits  of  turpentine.  A 
good  antiseptic  and  protective  is  the  following :  oxid  of 
zinc,  gr.  vj ;  chlorid  of  zinc,  gr.  xx ;  gelatin,  sij ;  distilled 
water,  3j. 

XXXI.  DISEASES  OF  THE  SKIN  AND  NAILS. 

Dermatitis  venenata  results  from  irritants  and  from 
garments  containing  arsenic,  but  is  generally  due  to  rhus- 
poisoning.  Rhus-poisoning  arises  from  the  poison-oak,  the 
poison-ash,  the  poison-ivy,  and  other  species  of  sumach. 
Actual  touching  of  the  plants  is  not  always  necessary. 

The  symptoms  are  burning  and  itching,  redness  and 
edema  of  the  face  and  hands.  A  vesicular  eruption  begins 
between  the  fingers,  and  the  eruption  and  the  inflammation 
spread  widely  over  the  body.  There  may  be  some  slight 
fever. 

The  treatmient,  when  a  moderate  area  is  involved,  com- 
prises the  application  of  cloths  wet  with  black  wash  or  lead- 
water  and  laudanum.  If  an  extensive  area  is  involved,  apply 
grindelia  robusta  (siv  to  Oj  of  water)  or  moisten  the  surface 
frequently  with  sweet  spirits  of  niter.  For  the  face  use 
borated-talc  powder.  Oxid-of-zinc  ointment  containing  10 
gr.  of  carbolic  acid  to  5J  gives  great  relief  A  i  :  8  solu- 
tion of  phenol  sodique  allays  pain  and  itching. 

Furuncle,  or  boil,  is  an  acute  and  circumscribed  inflam- 
mation of  the  deep  layer  of  the  true  skin  and  the  subcuta- 
neous cellular  tissue  following  on  bacterial  infection  of  a 
hair-follicle  or  a  sebaceous  gland.  A  boil  is  caused  by  in- 
fection of  a  hair-follicle,  through  a  slight  wound  (by  scratch- 
ing, shaving,  etc.),  with  the  staphylococcus  pyogenes  aureus. 
Boils  are  very  common  during  Bright's  disease,  diabetes, 
gout,  tuberculosis,  and  disorders  of  menstruation  and  diges- 
tion ;  and  crops  of  boils  are  apt  to  appear  during  convales- 
cence from  typhoid  fever.    Boils  are  commonest  in  the  spring. 


740  MODERN  SURGERY. 

and  sometimes  an  epidemic  of  furunculosis  appears  in  a  hos- 
pital, a  jail,  or  an  asylum. 

The  symptoms  of  a  boil  are  as  follows  :  a  red  elevation 
appears,  which  stings  and  itches ;  this  elevation  enlarges  and 
becomes  dusky  in  color ;  a  pustule  forms,  that  ruptures  and 
gives  out  a  very  little  discharge  which  forms  a  crust.  In- 
flammatoiy  infiltration  of  adjacent  connective  tissue  advances 
rapidly,  and  the  boil  in  about  three  days  consists  of  a  large, 
red,  tender,  and  painful  base  capped  by  a  pustule  and  some 
crusted  discharge.  In  rare  instances,  at  this  stage,  absorp- 
tion occurs,  but  in  most  cases  the  swelling  increases,  the 
discoloration  becomes  dusky,  the  skin  becomes  edematous, 
the  pain  becomes  fierce  and  pulsatile,  and  the  center  of 
the  boil  becomes  raised.  About  the  seventh  day  rupture 
occurs,  pus  runs  out,  and  a  "  core  "  of  necrosed  tissue  is 
found  in  the  center  of  a  ragged  opening.  This  core  con- 
sists of  the  sebaceous  gland  and  hair-follicle,  which  have 
undergone  coagulation-necrosis  (Warren).  In  a  day  or  two 
more  the  core  will  be  discharged,  and  healing  by  granulation 
will  occur.  A  blind  boil  lasts  only  three  or  four  days  and 
has  no  core.  The  constitution  often  shows  reaction  during 
the  progress  of  a  boil.  Boils  may  be  either  single  or  mul- 
tiple. The  development  of  one  boil  after  another,  or  the 
formation  of  several  boils  at  once,  is  known  as  "furunculosis." 
Boils  are  commonest  upon  the  neck  and  the  back. 

The  treatmient  consists  of  crucial  incision,  removal  of 
necrotic  tissue,  irrigation  with  peroxid  of  hydrogen  and  cor- 
rosive sublimate,  and  antiseptic  dressing. 

Aleppo  boils  (endemic  boils  of  the  tropics)  are  papules 
appearing  upon  the  exposed  parts  of  the  body.  These 
papules,  which  ulcerate  and  do  not  cicatrize  for  at  least  a 
year,  are  due  to  a  pathogenic  bacterium  and  leave  ineradi- 
cable scars. 

Carbuncle  (benign  anthrax)  is  a  circumscribed  infectious 
inflammation  of  the  deeper  layer  of  the  true  skin  and  of  the 
subcutaneous  tissue,  with  fibrinous  exudation  in  which 
multiple  foci  of  necrosis  arise  and  the  tissue  adjacent  to 
each  necrotic  plug  becomes  gangrenous.  The  infection 
takes  place  through  a  hair-follicle.  It  is  really  a  boil  with 
extensive  infiltration  of  adjacent  tissues.  A  boil  may  become 
a  carbuncle,  and  pus  from  a  carbuncle  inoculated  into  a 
healthy  person  may  cause  either  a  boil  or  a  carbuncle. 
The  causative  organism  seems  to  be  the  staphylococcus 
pyogenes  aureus.  The  local  symptoms  in  the  start  resem- 
ble those  of  a  boil,  but  the  constitution  sympathizes  from 


DISEASES   OF   THE   SKIN  AND   NAILS.  74 1 

the  beginning  (a  chill  and  a  septic  fever)  and  the  pain  is 
agonizing.  The  inflammatory  area  enlarges  enormously,  is 
boggy  to  the  touch,  is  dusky  in  color,  is  edematous,  and  the 
skin  is  not  freely  movable  over  the  deeper  parts.  In  a  few 
days  many  pustules  appear,  each  pustule  marking  the  site 
of  a  focus  of  necrosis.  Large  vesicles  filled  with  bloody 
serum  very  frequently  occur.  In  some  cases,  about  the 
tenth  day,  the  pustules  rupture,  the  necrotic  plugs  are  dis- 
charged, and  the  case  slowly  progresses  toward  cure  ;  but 
in  many  cases  the  carbuncle  spreads  at  the  periphery  while 
pustules  are  rupturing  near  the  center  of  inflammation,  and 
pus  forms  in  the  deeper  tissues,  reaching  the  surface  through 
many  small  openings,  each  of  which  is  partly  blocked  by  a 
plug  of  dead  tissue.  A  carbuncle  in  this  stage  resembles  a 
honeycomb,  discharges  bloody  pus,  and  large  masses  of 
skin  and  subcutaneous  tissue  are  destroyed.  The  entire 
carbuncular  mass  may  become  gangrenous,  and  a  sudden 
and  almost  complete  cessation  of  pain  points  to  this  compli- 
cation. An  ordinary  carbuncle  remains  acute  for  about 
three  weeks,  but  healing  requires  a  month  more.  The 
most  dangerous  situations  in  which  to  have  a  carbuncle  are 
the  face  and  neck  (tends  to  produce  septic  phlebitis,  septic 
clots  in  the  cerebral  sinuses,  or  infective  emboli).  The  most 
usual  positions  for  carbuncle  are  the  neck,  the  back,  and  the 
buttocks.  The  diagnosis  of  carbuncle  is  made  by  noting 
the  multiple  foci  of  necrosis  and  the  profound  constitu- 
tional involvement. 

Treatment. — Give  ether,  make  free  crucial  incisions,  re- 
move dead  and  necrosing  tissue  with  the  scissors  and 
forceps,  curet  pockets,  stop  hemorrhage  by  pressure  and 
hot  water,  cauterize  with  pKvc  carbolic  acid,  dust  with  iodo- 
form, pack  with  iodoform  gauze,  and  dress  with  hot  antiseptic 
fomentations.  Cover  the  gauze  with  a  piece  of  some  im- 
permeable material  and  lay  a  hot-water  bag  upon  the  dress- 
ing. Every  day,  or  several  times  a  day,  remove  the  dressings, 
wash  with  peroxid  of  hydrogen,  irrigate  with  corrosive-sub- 
limate solution,  dust  with  iodoform,  and  reapply  the  iodoform 
gauze  and  antiseptic  fomentation.  Keep  up  this  treatment 
until  sloughs  are  separated,  and  then  dress  with  dry  anti- 
septic gauze.  In  some  carbuncles  it  is  wise  to  extirpate 
the  entire  mass.  Secure  sleep  by  morphin,  give  quinin,  milk- 
punch,  and  nourishing  diet,  and  attend  to  the  bowels  and 
kidne}'s. 

Clavus,  or  Corn. — A  corn  is  a  tender,  painful,  and  cir- 
cumscribed thickening  of  the  epidermis,  and  is  commonest 


742  MODERN  SURGERY. 

over  one  of  the  joints  of  the  toes.  Hard  corns  are  situated 
on  exposed  parts  of  the  digits ;  soft  corns  appear  between 
the  digits,  where  the  parts  are  kept  constantly  moist.  Corns 
are  caused  by  pressure. 

Treatment. — By  wearing  well-fitting  boots  corns  upon  the 
toes  will  usuallydisappear.  Soak  the  feet  often  in  water  con- 
taining bicarbonate  of  sodium,  dry  them,  and  apply  a  circular 
corn-plaster  to  the  corn  to  take  off  the  pressure  of  the  boot 
Another  method  is  to  touch  the  corn  with  iodin  every  night 
and  pare  away  the  hard  tissue  every  morning.  An  old  and 
valuable  plan  is  to  paint  the  corn  every  night  with  a  mixture 
composed  of  salicylic  acid,  giss ;  extract  of  cannabis  indica, 
gr.  x;  and  collodion,  5j,  and  to  scrape  this  mixture  away 
every  morning.  Soft  corns  are  treated  by  washing  the  feet 
often  with  ethereal  soap,  drying,  gently  removing  the  sodden 
epithelium,  dusting  with  borated  talc,  and  placing  absorbent 
cotton  between  the  toes.  Incurable  soft  corns  require  the 
freshening  of  the  adjacent  sides  of  the  two  toes  and  suturing 
them  together  (thus  converting  two  toes  into  one).  In 
inflamed  corns  employ  rest  and  lead-water  and  laudanum, 
and  let  out  pus  when  it  forms.  Remember  that  in  old  per- 
sons the  cutting  of  a  corn  may  cause  senile  gangrene.  In 
the  inflamed  and  painful  feet  of  a  person  who  has  corns 
nothing  gives  so  much  relief  as  washing  the  feet  with 
ethereal  soap,  soaking  in  hot  water,  and  wrapping  the  feet 
for  half  an  hour  in  cloths  wet  with  a  mixture  composed 
of  linseed  oil  and  lime-water,  each,  ^ij,  and  spirits  of  cam- 
phor, Z]- 

Warts. — (See  page  231.) 

Onychia  is  inflammation  of  the  matrix  of  the  nail.  A 
"  run-around  "  is  suppuration  of  the  matrix  and  the  root  of 
the  nail,  of  traumatic  origin.  It  requires  incision,  trimming 
away  of  the  buried  edge  of  the  nail,  and  packing  with  iodo- 
form gauze.  Malignant  onychia,  which  is  inflammation  and 
ulceration  of  the  entire  matrix,  occurs  only  in  a  person  of 
dilapidated  constitution.  This  condition  requires  removal  of 
the  entire  nail,  cauterization  of  the  matrix,  dressing  with 
iodoform  gauze,  and  the  internal  use  of  stimulants,  tonics, 
and  nourishing  diet.  Ingrown  toe-nail  is  due  either  .  to 
lateral  hypertrophy  of  the  edge  of  the  nail  or  to  the  forcing 
of  the  soft  tissues  over  the  margin  of  the  nail.  The  con- 
dition is  treated  by  splitting  the  nail,  removing  the  piece  of 
nail,  the  soft  tissue,  and  the  adjacent  matrix,  and  dressing 
antiseptically. 


DISEASES  AND   INJURIES   OF  THE    THYROID    GLAND.    743 

XXXII.   DISEASES  AND   INJURIES  OF  THE  THYROID 

GLAND. 

Wounds  cause  violent  hemorrhage  which  is  difficult  to 
arrest.  Ligatures  cut  out  and  forceps  will  not  hold.  The 
hemorrhage  is  arrested  by  suture-ligatures,  purse-string  su- 
tures, the  actual  cautery,  or  removal  of  the  bulk  of  the  gland. 

The  thyroid  gland  may  be  absent  at  birth.  Congenital 
atrophy  or  congenital  hypertrophy  may  exist. 

Acquired  atrophy  leads  to  myxedema,  a  condition  char- 
acterized by  the  presence  of  a  firm  subcutaneous  swelling  in 
the  face,  neck,  and  limbs  ;  slow  speech  ;  mental  dulness  ;  and 
subnormal  temperature.  The  condition  is  identical  with  that 
produced  by  removal  of  the  entire  gland  (cachexia  struma- 
priva). 

Cretinism  is  a  form  of  idiocy  due  to  atrophy  of  glandu- 
lar elements  in  the  thyroid,  although  the  size  of  the  gland  is 
often  increased.  The  body  is  dwarfed ;  the  face,  neck,  and 
extremities  resemble  those  parts  in  myxedema,  and  a  low 
grade  of  idiocy  exists.  Myxedema  and  cretinism  are  treated 
by  the  internal  administration  of  thyroid  extract. 

Congestion  of  the  thyroid  may  be  caused  by  violent 
exertion,  prolonged  effort,  febrile  maladies  and  venous  ob- 
struction. It  is  treated  by  removing  the  cause  and  applying 
heat  locally.     Tracheotomy  may  be  required. 

Inflammation  of  the  thyroid  (acute  or  inflammatory 
goiter)  may  be  caused  by  a  septic  or  febrile  malady,  rheu- 
matism, muscular  strain  causing  vascular  rupture,  a  wound 
or  contusion  of  the  thyroid.  But  one  lobe  is  affected.  The 
ordinary  symptoms  of  inflammation  are  present.  In  addition 
there  are  dysphagia,  dyspnea,  venous  congestion  of  the  face, 
epistaxis,  nausea  and  vomiting,  and  possibly  delirium.  It 
may  terminate  in  resolution,  suppuration,  or  fibrous  indura- 
tion. 

Goiter. — A  goiter  is  an  enlargement  of  the  thyroid  gland 
not  due  to  malignant  tumor  or  to  inflammation.  Goiter  may 
affect  a  portion  of  one  lobe,  both  lobes,  or  both  lobes  and  the 
isthmus,  and  it  may  occur  sporadically  or  endemically.  In 
Switzerland  it  is  very  common.  Among  the  alleged  causes  are 
the  playing  of  wind-instruments,  the  drinking  of  snow-water, 
and  the  use  of  water  impregnated  with  the  salts  of  lime.  He- 
reditary influence  is  frequently  noted.  The  forms  of  goiter 
are  as  follows  :  simple  liypcrtrophy,  a  hypertrophy  of  the 
gland-tissue,  usually  symmetrical,  in  reality  an  adenoma; 
cystic  goiter  or  brottchocele,  in  which  cysts  form  in  hypertro- 


744  MODERN  SURGERY. 

phied  glands,  or  rarely  in  non-hypertrophied  thyroids,  the 
cysts  being  either  single  or  multiple,  being  due  to  mucoid  or 
colloid  degeneration,  and  containing  a  fluid  sometimes  clear 
and  thin,  sometimes  viscid,  and  often  coffee-ground  in  char- 
acter ;  and  fibrous  goiter,  a  fibrous  induration  which  is  apt  to 
arise  in  old  bronchoceles,  and  which  may  pass  into  a  calca- 
reous condition.  Parenchymatous  goiter  is  enlargement  of 
the  whole  gland.  By  the  term  malignant  goiter  we  mean 
malignant  disease  of  the  thyroid  gland,  either  sarcoma  or 
carcinoma. 

The  symptonis  are — congestion  of  the  head  and  neck  from 
enlargement  of  veins ;  occasionally  cerebral  symptoms  (ane- 
mia, syncope,  even  convulsions)  from  pressure  on  carotids  ; 
irritation  of  recurrent  laryngeal  nerve  (causing  spasm  of  the 
glottis  or  laryngeal  paralysis) ;  compression  of  the  trachea 
(dyspnea).  Rapidly-growing  goiters  are  often  fatal ;  slow- 
growing  goiters  are  rarely  fatal.  A  goiter  moves  up  and 
down  as  the  patient  swallows.  A  malignant  goiter  grows 
rapidly,  becomes  adherent,  infiltrates,  and  quickly  produces 
metastasis.  Both  sarcoma  and  carcinoma  produce  metastasis 
by  way  of  the  venous  system. 

Treatment. — lodid  of  potassium  and  arsenic  internally 
have  been  advised ;  ointment  of  red  oxid  of  mercury  locally 
is  advocated  by  some  writers.  The  local  use  of  iodin  benefits 
many  cases.  The  administration  of  thyroid  extract  may  do 
much  good.  Cystic  goiters  may  be  aspirated  and  injected 
with  a  solution  of  iodin.  Electrolysis  may  benefit  a  soft 
goiter,  the  negative  pole  being  pushed  into  the  growth,  the 
positive  pole  being  applied  to  its  surface.  In  considering 
the  propriety  of  operation  remember  that  a  goiter  which 
begins  at  puberty  may  pass  away.  We  should  operate  on 
every  non-malignant  goiter  which  is  increasing  rapidly  in  size, 
and  on  even,^  goiter  which  causes  much  respiratory  trouble, 
but  should  not  operate  simply  for  deformity  (Bergeat).  If 
enucleation  or  extirpation  is  performed,  do  not  give  ether  or 
chloroform.  These  agents  greatly  increase  bleeding,  and  are 
dangerous.  Do  the  operation  without  any  anesthetic  or  with 
the  aid  of  local  anesthesia  (cocain,  eucain,  or  Schleich's  fluid). 
It  is  a  great  advantage  to  have  the  patient  conscious,  because 
by  asking  him  to  speak  during  the  operation  the  surgeon 
can  tell  if  the  recurrent  lar}mgeal  nerve  is  being  touched. 
In  most  cases  intraglandular  enucleation  is  performed,  in 
some  cases  extraglandular  enucleation,  in  other  cases  these 
two  methods  are  combined  (Bergeat).  Ligation  of  the 
thyroid  arteries  has  been  recommended.    Enucleation,  ifpos- 


DISEASES  AXD   INJURIES   OF   THE    THYROID    GLAND.    745 

sible,  is  the  desirable  operation.  It  may  easily  be  employed 
for  the  removal  of  a  single  colloidal  or  cystic  area  (Socin). 
Thyroidectomy  or  extirpation  is  employed  when  enuclea- 
tion is  impossible.  The  entire  thyroid  is  not  removed ;  a 
portion  of  the  gland  is  left  behind,  otherwise  myxedema  will 
arise  (Kocher).  Unilateral  extirpation  is  the  usual  method. 
In  sarcoma  or  cancer  of  the  thyroid  extirpation  may  be 
attempted.  The  operation  will  occasionally  prolong  life, 
but  it  will   rareh"  effect  a  cure. 

Bxophthalmic  Goiter  (Graves's  Disease;  Basedow's 
Disease;  Pulsating  Goiter). — In  atypical  case  there  are  rapid 
pulse,  protrusion  of  the  eyeballs,  and  enlargement  of  the  thy- 
roid gland ;  but  any  one  of  these  conditions  may  be  absent. 
The  enlargement  may  be  unilateral,  but  is  usually  bilateral. 
A  systolic  bruit  is  usually  audible  over  the  thyroid  region. 
Von  Graefe's  sign  may  be  present ;  this  consists  of  retraction 
of  the  eyelids,  and  inability  of  the  lids  to  follow  the  eyes  in 
looking  down.  The  lids  in  some  cases  cannot  be  completely 
closed,  and  when  the  eyeball  is  suddenly  turned  up  the  lid 
and  brow  may  fail  to  act  together.  In  some  cases  the  lids 
pulsate,  in  some  ocular  palsies  exist,  in  others  photophobia  or 
nystagmus.  Patients  may  suffer  from  neuralgia,  colic,  choreic 
movements,  tremor,  flushes  of  heat,  and  gastric  crises.  Dysp- 
nea often  exists,  and  albuminuria  and  polyuria  are  not  un- 
common. Hemoptysis,  hematemesis,  or  mental  disturbance 
is  sometimes  noted. 

Exophthalmic  goiter  may  arise  after  emotional  excitement 
or  depression,  during  pregnancy,  or  during  the  existence  of 
locomotor  ataxia,  paresis,  epilepsy,  neurasthenia,  hysteria, 
and  other  nervous  troubles.  Cohen  considers  it  to  be  a  vaso- 
motor ataxia.  Its  real  cause  is  uncertain  ;  but  is  probably 
the  action  upon  the  sympathetic  s}-stem  of  some  poisonous 
product  of  thyroid  action. 

Treatment. — Thyroid  extract  more  often  does  harm  than 
good.  Electricity  is  said  to  be  of  benefit.  Most  cases  are 
treated  by  improving  the  general  health,  and  employing  digi- 
talis. Thymus  extract  has  been  used  by  some.  Extirpation 
of  the  cervical  ganglion  of  the  sympathetic,  and  division 
of  the  nerve  below  the  ganglion,  have  been  employed  with 
benefit  (Jaboulay).  Ligation  of  the  thyroid  arteries  may  do 
good.  Incomplete  removal  is  the  operation  commonly  em- 
ployed in  severe  cases  ;  it  has  cured  eighty  per  cent,  of  the 
cases  operated  upon.  In  some  cases  thyroid  intoxication 
follows  operation.  In  other  cases  ver}'  rapid  growth  follows 
incomplete  removal,  and  the  operation  seems  actually  to  have 


746  MODERN  SURGERY. 

done  harm.  Sudden  death  occasionally  follows  the  opera- 
tion of  thyroidectomy.  The  removal  of  an  exophthalmic 
goiter  is  difficult ;  the  capsule  and  blood-vessels  rupture  from 
slight  force,  and  the  use  of  ether  and  chloroform  is  very 
dangerous.  All  cases  should  not  be  operated  upon  ;  in  fact, 
only  those  cases  should  be  operated  upon  in  which  medical 
treatment  has  proved  futile,  or  in  which  there  is  profound 
toxemia  or  excessive  dyspnea.  If  the  operation  is  performed,, 
neither  ether  nor  chloroform  should  be  given,  as  either  of 
these  agents  will  greatly  increase  bleeding  and  prove  dan- 
gerous. Operation  is  to  be  done  under  local  anesthesia 
(eucain,  cocain,  or  Schleich's  fluid). 

XXXIII.    DISEASES    AND    INJURIES    OF    THE 
LYMPHATICS. 

I/ymphangitis  is  inflammation  of  lymphatic  vessels.  Re- 
ticular lymphangitis,  which  is  inflammation  of  lymphatic 
radicals,  is  seen  in  some  circumscribed  inflammations  of  the 
skin.  It  is  apt  to  attack  the  hands,  causing  redness  and 
swelling,  fading  at  the  point  of  initial  trouble  while  it  spreads 
at  the  periphery ;  it  is  caused  by  micro-organisms  derived 
from  decomposing  animal  matter  (Rosenbach),  Erysipelas 
also  causes  it  (see  Erysipelas).  Tubular  lymphangitis,  which 
is  due  to  the  entry  into  the  lymphatic  ducts  of  virulent  micro- 
organisms or  toxic  materials,  is  seen  in  dissecting-wounds, 
septic  wounds,  snake-bites,  etc.  It  is  announced  by  edema 
and  by  minute,  hard,  red  streaks  running  from  the  wound  up 
the  extremity.     Suppuration  may  occur. 

Infective  lymphadenitis,  or  inflammation  of  the  glands, 
may  follow  lymphangitis  or  may  be  due  to  the  deposition  of 
infective  material,  the  lymph-vessels  not  being  inflamed.  In 
septic  lymphadenitis  there  are  pain,  tenderness,  and  sweHing ; 
in  severe  cases  there  are  chill  and  septic  fever.  Suppuration 
may  arise.  The  treatment  is  to  drain  and  asepticize  the 
wound,  to  apply  iodin,  blue  ointment,  or  ichthyol  over  the 
glands  and  vessels,  and  to  employ  rest  and  compression. 
Internally,  milk  punch,  quinin,  and  nourishing  diet  are  re- 
quired. If  the  glands  do  not  rapidly  diminish  in  size  after 
disinfection  of  a  wound,  and  if  they  are  in  an  accessible 
region,  extirpate  them.  If  suppuration  of  the  glands  occurs, 
incise  and  drain. 

Acute  lymphadenitis,  or  acute  inflammation  of  the  lym- 
phatic glands,  may  be  due  to  tubercle,  syphilis,  glanders,  cold, 
or  traumatism.     Suppuration  may  or  may  not  occur.     In  in- 


DISEASES  AND  INJURIES   OF  THE  LYMPHATICS.    747 

flammatory  lymphadenitis  there  are  pain,  heat,  and  nodular 
swelHng.  In  severe  cases  there  is  fever.  The  treatnieiit  is 
to  asepticize  any  area  of  infection,  place  the  glands  at  rest, 
apply  cold  and  lead-water  and  laudanum,  or  inject  into  the 
gland  every  day  5  minims  of  a  3  per  cent,  solution  of  carbolic 
acid  to  prevent  suppuration.  If  the  glands  do  not  rapidly 
shrink,  extirpate  them.  If  pus  forms,  evacuate,  drain,  and 
asepticize. 

Chronic  lymphadenitis  is  almost  invariably  syphilitic  or 
tubercular.  It  requires  constitutional  treatment  and  the  local 
use  of  ichthyol,  iodin,  or  blue  ointment.  If  these  remedies 
are  not  rapidly  successful,  tubercular  glands  should  be  re- 
moved, but  syphilitic  glands  will  rarely  require  such  radical 
treatment. 

I/ymphangiectasis  (varicose  lymphatics),  or  dilatation 
of  the  lymphatic  vessels,  is  due  to  obstruction.  It  results, 
as  a  rule,  from  chronic  lymphangitis  or  the  pressure  of  a 
tumor,  and  is  most  usually  situated  in  the  pubic,  the  inguinal, 
or  the  scrotal  regions,  or  on  the  inner  side  of  the  thigh. 
There  are  two  forms  :  the  varicose,  in  which  the  vessels  have 
a  tortuous  outline,  like  varicose  veins,  but  are  covered  only 
by  surface-epithelium ;  and  lymphatic  warts  (lymphangioma 
circumscriptum),  in  which  wart-like  masses  spring  up,  these 
masses  being  covered  with  epithelium  and  filled  with  lymph. 
In  most  cases  of  lymphangiectasis  there  is  considerable  hard 
edema.  Rupture  of  the  dilated  vessel  causes  a  flow  of  lymph 
{/yviphorrhca). 

I/ymphangiotna  is  an  advanced  stage  of  lymphangi- 
ectasis (page  226).  The  treatment  in  mild  cases  is  to 
pierce  each  vesicle  with  the  negative  pole  of  a  galvanic 
battery  and  pass  a  current.  In  severe  cases  destroy  the 
mass  with  the  Paquelin  cautery  or  excise  it  with  a  knife  or 
with  scissors. 

Elephantiasis. —  Tmc  elephantiasis  (elephantiasis  Ara- 
bum)  is  chronic  hypertrophy  of  the  skin  and  subcutaneous 
tissues  following  upon  a  lymphangiectasis  produced  by  a 
nematode  worm  (the  filaria  sanguinis  hominis).  Spitrious 
elephantiasis  is  hypertrophy  of  the  skin  and  subcutaneous 
tissue  due  to  chronic  inflammation  (in  a  leg  which  pos- 
sesses an  ancient  ulcer,  or  in  the  scrotum  of  a  man  with 
urinary  fistula).  The  treatment  is  massage  and  bandaging, 
sometimes  ligation  of  the  artery  of  supply,  extirpation,  or 
amputation. 

Malignant  I/ymphoma,  or  Hodgkin's  Disease. — 
(See  page  221.) 


748.  MODERN  SURGERY. 

XXXIV.  BANDAGES. 

A  bandage  is  a  fibrous  material  which  is  rolled  up  and  is 
then  employed  to  retain  dressings,  applications,  or  appliances 
to  a  part,  to  make  pressure,  or  to  correct  deformity.  It  may 
be  composed  of  plain  gauze,  of  gauze  infiltrated  with  plaster- 
of-Paris  or  soaked  in  silicate  of  sodium,  of  gauze  wet  with 
corrosive-sublimate  solution,  of  flannel,  of  calico,  or  of  un- 
bleached muslin.  Unbleached  muslin,  which  is  the  best 
material  for  general  use,  is  washed  to  remove  the  sizing, 
is  torn  into  strips,  and  the  edges  are  stripped  of  selvage. 
One  end  is  folded  to  the  extent  of  six  inches,  this  is  folded 
upon  itself  again  and  again  until  a  firm  center  is  formed, 
and  over  this  center  the  bandage  is  rolled.  In  a  well-rolled 
bandage  the  center  cannot  be  pushed  out  of  the  roll.  A 
roller  bandage  is  divided  into  the  initial  end,  which  is  within 
the  roll,  the  body  or  rolled  part,  and  the  terminal  end,  which 
is  free.  In  applying  a  bandage  the  outer  surface  of  the 
terminal  end  is  first  laid  upon  the  part. 

A  cylindrical  part  of  the  body  may  be  covered  by  a  cir- 
cular bandage,  each  turn  exactly  covering  the  previous  turns. 
A  conical  part  may  be  covered  by  a  spiral  bandage,  each  turn 
ascending  a  little  higher  than  the  previous  turn.  As  each  turn 
of  a  spiral  bandage  is  tight  at  its  upper  and  loose  at  its  lower 
edge,  the  reverse  was  devised  to  correct  this  inequality; 
hence  a  conical  part  should  be  covered  by  a  spiral  reversed 
bandage.  To  make  a  reverse  hold  the  roller  in  the  right 
hand,  start  the  bandage  obliquely  upward  (do  not  have 
more  than  six  inches  of  slack),  place  the  thumb  across 
the  fresh  turn,  fold  the  bandage  down  without  traction, 
and  do  not  make  traction  until  the  turn  has  been  carried 
well  around  the  limb.  A  projecting  point  is  covered  with 
figure-of-8  turns.  The  groin,  shoulder,  breast,  or  axilla  can 
be  covered  by  figure-of-8  turns,  each  succeeding  turn  ascend- 
ing and  covering  two-thirds  of  the  previous  turn  and  form- 
ing a  figure  like  "  the  leaves  on  an  ear  of  corn."  Such  a 
figure  is  called  a  "  spica."  In  bandaging  an  extremity  the 
peripheral  turns  should  be  tighter  than  the  turns  nearer  the 
body.  Never  apply  a  tight  bandage  to  the  leg  or  the  arm 
without  including  the  foot  or  the  hand.  In  firm  dressings 
leave  the  ends  of  the  fingers  exposed,  and  use  them  as  an 
index  of  the  condition  of  the  circulation  in  the  part. 

Spiral  Reversed  Bandage  of  the  Upper  Extremity. 
— To  apply  this  form  of  bandage  use  a  roller  two  and  a  half 
inches  wide  and  eight   yards  long.     Take  a  circular  turn 


BANDAGES. 


749 


about  the  wrist,  and  a  second  turn  to  hold  the  first ;  pass 
obHquely  across  the  back  of  the  hand  to  the  extremities  of 
the  fingers ;  ascend  the  hand  to  the  root  of  the  thumb  by- 
several  spiral  turns  ;  cover  the  wrist  by  ascending  figure-of-8 
turns  ;  ascend  the  forearm  by  spiral  reversed  turns ;  cover 
the  elbow  by  a  figure-of-8,  and  the  arm  by  spiral  reversed 
turns  ;  end  the  bandage  by  two  circular  turns,  and  pin  them 
together  (Fig.  254). 


Fig.  254. — Spiral  reversed  bandage  of  the  upper  extremity. 

Spiral  Bandage  of  All  the  Fingers  (Gauntlet).— The 
gauntlet  bandage  requires  a  roller  one  inch  wide  and  one 
and  a  half  yards  long.  Take  two  circular  turns  around  the 
wrist,  pass  obliquely  across  the  wrist  to  the  root  of  the  thumb, 
and  descend  to  its  tip  by  spiral  turns ;  cover  in  the  thumb 
by  ascending  spiral  reverses,  and  return  to  the  wrist.  Cover 
in  each  successive  finger  in  the  same  manner,  and  terminate 
by  two  circular  turns  around  the  wrist  (Fig.  255). 


Fig.  255. — Gauntlet  bandage. 


Fig.  256. — Demi-gauntlet  bandage. 


Spiral  Bandage  of  the  Palm  or  Dorsum  of  the 
Hand  (Demi-gauntlet). — The  demi-gauntlet  requires  a  roller 
one  inch  wide  and  four  yards  long.  This  bandage  has  only 
a  limited  value ;  it  must  not  be  applied  tightly,  as  it  makes 
much  pressure  at  the  finger-roots,  but  leaves  the  fingers  free. 
If  it  is  desired  to  cover  the  palm,  supinate  the  hand ;  if  to 
cover  the  dorsum,  pronate  the  hand.    Take  two  circular  turns 


75©  MODERN  SURGERY. 

around  the  wrist,  sweep  around  the  root  of  the  thumb,  and 
return  to  the  point  of  origin.  Treat  each  finger  in  the  same 
way.     End  by  circular  turns  around  the  wrist  (Fig.  256). 

Spica  of  the  Thumb. — For  this  bandage  use  a  roller 
one  inch  wide  and  three  yards  long.  Start  at  the  wrist,  and 
reach  the  tip  of  the  thumb  as  in  applying  a  spiral  bandage 
of  a  finger.  Make  a  series  of  ascending  figure-of-8  turns 
between  thumb  and  wrist,  each  ascending  turn  overlying 
two-thirds  of  the  previous  turn ;  terminate  with  a  circular  of 
the  wrist  (Fig.  257). 


Fig.  257. — Spica  of  the  thumb. 


Selva's  Thumb  Bandage  (Fig.  258).— Lay  the  terminal 
end  of  the  bandage  on  the  outer  side  of  the  second  phalanx 
of  the  thumb,  near  the  base  of  the  phalanx.     Carry  it  over 


Fig.  258. — Selva's  thumb-bandage  applied. 

the  palmar  side  of  the  pulp  of  the  last  phalanx  to  the  inner 
side  of  the  second  phalanx.  The  surgeon  holds  this  turn  in 
place  with  his  left  thumb  and  index  finger.  The  roller  is 
returned  in  a  recurrent  manner  to  its  place  of  origin,  over- 
laps the  preceding  turn,  and  is  placed  as  much  as  possible 
on  the  dorsum.  The  roller  is  carried  over  the  dorsum  of 
the  terminal  phalanx  and  is  turned  around  the  tip,  the  loop 
crossing  over  the  center  of  the  nail.  Figure-of-8  turns  are 
now  made  over  the  dorsum  of  the  hand,  over  the  palm,  and 
returning  to  the  terminal  phalanx,  and  an  ascending  spica 
is  made.^ 

Spiral  Reversed  Bandage  of  the  I/Ower  Extremity. 
— Take  a  roller  two  and  a  half  inches  wide  and  seven  yards 
long,  and  make  two  circular  turns  just  above  the  malleoh, 
and  an  oblique  turn  across  the  dorsum  of  the  foot  to  the 

1  Medical  Neius,  Sept.  28,  1895. 


BANDAGES. 


751 


metatarsophalangeal  articulation  ;  make  a  circular  turn,  and 
cover  the  foot  with  ascending  spiral  reversed  turns  ;  return  to 
the  ankle  by  a  figure-of-8  ;  ascend  the  leg  by  spiral  reverses  ; 
cover  the  knee  by  a  figure-of-8,  and  the  thigh  by  spiral  re- 
verses ;  terminate  by  two  circular  turns  (Fig.  259). 

Bandage  of  the  Foot  covering  the  Heel  (American 
Bandage  of  the  Foot). — Take  a  roller  two  and  a  half  inches 

wide  and  seven  yards  long.  The 
bandage  is  begun  as  is  a  spiral 
reversed  bandage  of  the  lower 
extremity.  After  the  foot  is  well 
covered  by  ascending  spiral  re- 
versed turns  carry  the  bandage 
directly  around  the  point  of  the 


Fig.  259. — Spiral  reversed  bandage 
of  the  lower  extremity. 


Fig.  260. — Method  of  covering  the  hee 


heel  and  return  to  the  instep ;  from  this  point  carry  it 
around  the  back  of  the  ankle,  down  the  side  of  the  heel, 
under  the  heel,  up  to  the  instep,  around  the  ankle  in  the 
opposite  direction,  down  the  opposite  side  of  the  heel,  and 
under  the  heel  and  up  to  the  instep ;  take  the  roller  to 
above  the  malleoli,  and  end  by  a  circular  turn  (Fig.   260). 

Bandage  of  the  Foot  not  covering  the  Heel  (French 
Method). — Take  a  roller  two  and  a  half  inches  wide  and  six 
yards  long.  Make  a  spiral  reversed  bandage  of  the  foot  and 
a  figure-of-8  of  the  ankle-joint  (Fig.  261). 

Spiral  Bandage  of  the  Foot  covering  the  Heel 
(Ribbail's  Bandage ;  Spica  of  the  Instep). — Take  a  roller 
two  and  a  half  inches  wide  and  six  yards  long.  Apply  as 
a  spiral  reversed  bandage  of  the  lower  extremity  until  the 
metatarsus  is  well  covered.  Carr}^  the  bandage,  parallel  with 
the  margin  of  the  foot  (the  inner  or  outer  margin,  according 
as  to  whether  it  is  the  left  foot  or  the  right),  around  the  pos- 
terior aspect  of  the  heel,  along  the  opposite  margin  of  the 
foot  to  cross  the  orieinal  turn  at  the  median  line  of  the  dor- 


752 


MODERN  SURGERY. 


sum.  Make  a  number  of  these  ascending  turns,  each  turn 
covering  in  three-fourths  of  the  previous  turn ;  terminate  by 
circular  turns  above  the  ankle  (Fig.  262). 


Fig.  261. — Figure-of-8  bandage  of  the  ankle. 


Fig.  262. — Spica  of  the  instep. 


Crossed  Bandage  of  both  i^yes  (Figure-of-8  of  both 
Eyes).' — Take  a  roller  two  inches  wide  and  six  yards  long. 
Make  a  circular  turn  around  the  forehead  from  right  to  left, 
a  second  turn  to  hold  the  first,  a  turn  downward  over  the 
left  eye,  under  the  left  ear,  around  the  back  of  the  neck,  and 
upward  under  the  right  ear  and  over  the  right  eye ;  repeat 
these  turns,  and  terminate  by  a  circular  turn  of  the  forehead 
(Fig.  263). 


Fig.  263. — Crossed  figure-of-8  bandage 
of  both  eyes. 


Fig.  264.- 


-Barton's  bandage  or  figure-of-8 
of  the  jaw. 


Barton's  Bandage  (Figure-of-8  of  t*he  Jaw  and  Occiput). 
— Take  a  roller  two  inches  wide  and  five  yards  long.  Place 
the  initial  extremity  of  the  bandage  behind  the  inion ;  pass 
over  the  right  parietal  bone,  across  the  vertex,  down  the  left 
side  in  front  of  the  ear,  under  the  chin,  up  the  right  side  in 


BANDAGES. 


753 


front  of  the  ear,  across  the  vertex,  and  across  the  left  parietal 
bone  to  the  point  of  origin.  A  turn  is  now  taken  forward  along 
the  right  side  of  the  jaw  to  the  chin,  and  backward  along  the 
left  side  of  the  jaw  from  the  chin  to  the  nape  of  the  neck ; 
repeat  these  turns,  and  pin  the  points  of  junction  (Fig.  264). 
In  Barton's  bandage  the  ear  lies  in  an  uncovered  triangle. 
The  bandage  may  be  finished  by  circular  turns  around  the 
forehead.  Barton's  bandage  is  used  for  fracture  of  the 
lower  jaw. 

Borsch's  eye-bandage  is  convenient  and  useful  (Fig. 
265).  A  narrow  bandage  is  laid  along  the  head  and  per- 
mitted to.  hang  down  the  face  in  front  of  the  sound  eye.  A 
circular  bandage  is  applied  around  both  eyes  and  over  the 
narrow  bandage  (a).  The  narrow  strip  is  lifted  and  pinned, 
and  the  sound  eye  is  thus  uncovered.  Of  course,  the  pos- 
terior end  of  A  should  first  be  pinned  to  the  circular  turn. 


Fig.  265. — Borsch's  eye-bandage  :  a,  first  step  ;  b,  second  step. 


Gibson's  Bandage. — Take  a  roller  two  inches  wide  and 
six  yards  long.  Make  three  vertical  turns  around  the  head 
and  the  jaw  in  front  of  the  ear ;  reverse  the  bandage  above 
the  level  of  the  ear,  and  carry  it  horizontally  around  the  fore- 
head and  head  three  times ;  drop  the  bandage  to  the  nape 
of  the  neck,  and  take  three  turns  around  the  neck  and  jaw ; 
terminate  by  taking  from  the  nape  of  the  neck  a  half  turn 
upward,  carrying  the  bandage  forward  to  the  forehead,  and 
pinning  it  over  the  neck  and  over  the  forehead.  Pin  each 
point  of  junction  (Fig.  266).  Gibson's  bandage  is  used  for 
fracture  of  the  lower  jaw. 

Crossed  Bandage  of  the  Angle  of  the  Jaw  (Oblique 
Bandage  of  the  Jaw). — Take  a  roller  two  inches  wide  and  six 

48 


754 


MODERN  SURGERY. 


yards  long.  Make  a  circular  turn  around  the  forehead  to- 
ward the  affected  side,  and  a  second  turn  to  hold  the  first ; 
take  the  turn  to  the  back  of  the  neck  ;  carry  it  forward  on  the 
sound  side,  under  the  ear  and  chin ;  now  make  a  series  of  turns 
around  the  head  and  jaw,  in  front  of  the  ear  on  the  injured 
side,  but  back  of  the  ear  on  the  sound  side :  these  turns 
successively  advance  on  the  sound  side  only ;  terminate  by 
going  backward  under  the  ear  of  the  sound  side  to  the  nape 
of  the  neck,  and  then  by  taking  two  circular  turns  around 


Fig.  266. — Gibson's  bandage. 


Fig.  267. — Oblique  or  crossed  bandage 
of  the  angle  of  the  jaw. 


the  forehead  (Fig.  267).  This  bandage  is  used  for  fractures 
of  the  ramus  of  the  jaw  and  for  holding  dressings  upon  the 
face  and  the  cranium. 

Spica  of  the  Groin  (Figure-of-8  of  the  Thigh  and  Pel- 
vis).— For  one  groin  the  roller  is  three  inches  wide  and  seven 
yards  long ;  for  both  groins,  three  inches  wide  and  ten  yards 
long.  Take  two  circular  turns,  from  right  to  left,  around  the 
waist,  then  down  over  the  front  of  the  right  groin,  around 
the  back  of  the  thigh,  up  over  the  front  of  the  right  groin, 
around  the  waist,  down  over  the  front  of  the  left  groin, 
around  the  back  of  the  thigh,  up  over  the  left  groin,  and 
around  the  waist.  The  map  being  thus  laid  out,  the  turns 
are  continued  and  ascended,  each  turn  overlying  one-third 
of  the  previous  turn,  and  the  bandage  is  completed  by  a 
circular  turn  around  the  waist  (Fig.  268).  Pin  the  crossed 
pieces. 

Spica  of  the  Shoulder. — Take  a  roller  two  and  a  half 
inches  wide  and  seven  yards  long.  Make  a  circular  turn 
and  several  spiral  reversed  turns  around  the  upper  arm  ;  then, 
coming  from  behind  forward,  carry  the  bandage   over  the 


BANDAGES. 


755 


shoulder,  across  the  front  of  the  chest,  through  the  opposite 
arm-pit,  and  return  across  the  back  to  the  shoulder.  Make 
successive  and  advancing  turns  (Fig.  269). 


Fig.  268. — Spica  of  the  groin. 


Fig.  269. — Spica  of  the  shoulder. 


Figure-of-8  bandages  of  the  elbow,  both  shoulders  (pos- 
terior figure-of-8),  the  neck  and  axilla,  and  of  the  breast 
are  shown  in  Figs.  270,  271,  272,  277. 


Fig.  270. — Figure-of-8  bandage  of  the  elbow. 


Fig.  271. — Posterior  figure-of-8  of  both 
shoulders. 


Velpeau's  Bandage. — Take  a  roller  two  and  a  half 
inches  wide  and  ten  yards  long.  Place  the  palm  of  the  hand 
of  the  injured  side  upon  the  shoulder  of  the  sound  side,  inter- 
posing cotton  between  the  arm  and  the  side.  Start  the  band- 
age at  the  axilla  of  the  sound  side  posteriorly,  carry  it  across 
the  back  to  the  shoulder  of  the  injured  side,  down  the  front  of 


756 


MODERN  SURGERY. 


the  arm  and  under  the  arm  just  above  the  elbow,  returning  to 
the  point  of  origin ;  repeat  this  turn,  but,  on  reaching  the  axilla 
the  second  time,  cross  the  back  and  pass  around  the  chest, 
including  the  arm ;  keep  on  with  these  turns,  each  alternate 
turn  going  over  the  injured  clavicle,  each  alternate  turn 
encircling  the  arm  and  the  body,  the  first  turns  advancing 


Fig.  272. — Figure-of-8  of  neck  and  axilla. 


Fig.  273. — Velpeau's  bandage. 


and  the  second  turns  ascending  (Fig.  273).     Pin  the  crossed 
pieces.     This  bandage  is  used  for  fracture  of  the  clavicle. 

Desault's  Apparatus. — This  apparatus  consists  of  three 
rollers,  a  pad,  and  a  sling.  Each  roller  is  two  and  a  half 
inches   wide   and   seven   yards    long.      The   pad,  which  is 


Fig.  274. — Desault's  bandage,  first  roller. 


Fig.  275. — Desault's  bandage,  second  roller. 


wedge-shaped,  is  inserted  into  the  axilla  with  the  base  up. 
The  first  roller  is  used  to  hold  the  pad  (Fig.  274).  The 
second  roller  binds  the  arm  to  the  side  over  the  pad.     This 


BANDAGES. 


757 


pad  is  a  fulcrum,  the  shoulder  is  the  weight,  the  arm  is  the 
lever,  and  the  second  roller  of  Desault  corrects  the  inward 
deformity  of  a  fractured  clavicle  (Fig.  275).  The  third 
roller  corrects  the  downward  and  forward  displacement.  It 
starts  in  the  axilla  of  the  sound  side  anteriorly,  crosses  the 
chest  to  the  shoulder  of  the  injured  side,  runs  down  the 


Fig.  276. — Desault's  bandage,  th'rd  roller.  Fig.  277. — Figure-of-8  bandage  of  the  breast. 

back  of  the  arm,  around  the  elbow,  and  crosses  the  chest 
to  the  point  of  origin,  forming  the  anterior  triangle ;  it  is 
now  carried  through  the  axilla  of  the  sound  side  to  the 
back,  crosses  the  back  to  the  shoulder  of  the  injured  side, 
runs  down  the  front  of  the  arm,  around  the  elbow,  and 
across  the  back  to  the  axilla  of  the  sound  side,  forming  the 
posterior  triangle  (Fig.  276).  The  formula  for  the  Desault 
bandage  is  :  start  in  the  axilla  of  the  sound  side  anteriorly, 
run  from  the  axilla  to  the  shoulder,  from  the  shoulder  to  the 
elbow,  from  the  elbow  to  the  axilla,  and  pass  to  the  back ; 
from  the  axilla  to  the  shoulder,  from  the  shoulder  to  the 
elbow,  from  the  elbow  to  the  axilla,  and  pass  to  the  front. 
Pin  the  crossed  pieces  and  hang  the  hand  in  a  sling  (Fig. 
276). 

Recurrent  Bandage  of  the  Head. — Take  a  roller  two 
inches  wide  and  six  yards  long.  Make  two  circular  turns 
horizontally  around  the  forehead  and  head  ;  when  the  middle 
of  the  forehead  is  reached,  catch  the  bandage,  take  a  half 
turn,  carry  the  bandage  to  the  occiput,  let  an  assistant  catch 
it,  take  a  half  turn,  bring  the  roller  forward  to  the  forehead, 
covering  a  portion  of  the  preceding  turn ;  continue  this  pro- 
cess until  the  scalp  is  well  covered ;  terminate  with  two  cir- 
cular turns  around  the  forehead  and  head  (Fig.  2"]^^.     It  is 


/y 


MODERN  SURGERY. 


often   advisable  to  take  a  turn  around  the  head  and  chin. 
Pin  the  crossed  pieces. 


Fig.  278. — Recurrent  bandage  of  the  head. 


Fig.   279. — Recurrent  bandage  of  a  stump. 


Recurrent  Bandage  of  a  Stump. — Take  a  roller  two 
inches  wide  and  six  yards  long.  Make  two  light  circular 
turns  around  the  root  of  the  stump ;  make  recurrent  turns 
covering  the  stump  as  is  done  in  covering  the  head  ;  take  a 
circular  turn  around  the  root  of  the  stump,  obhque  turns  to 
the  top  of  the  stump,  circular  turns  around  the  tip,  and 
apply  an  ascending  spiral  reversed  bandage  (Fig.  279). 

T-Bandage  of  the  Perineum.  —  Pass  the  transverse 
part  around  the  body  above  the  iliac  crests,  and  pin  it  in 
front ;  bring  one  of  the  tails  over  the  dressing  and  up 
between  the  thigh  and  the  genitals  of  one  side,  and  the 
other  tail  over  the  dressing  and  up  between  the  thigh  and 
the  genitals  of  the  opposite  side ;  secure  these  tails  to  the 
horizontal  band. 

Handkerchief  Bandages. — Take  unbleached  muslin 
one  yard  square.  The  muslin  folded  once  makes  an  oblong 
bandage ;  bringing  its  diagonal  angles  together  makes  a 
triangle  bandage ;  a  cravat  is  formed  by  folding  a  triangle 
bandage  from  summit  to  base ;  a  cord  is  a  twisted  cravat. 
The  triangle  makes  an  admirable  sling. 

Fixed  Dressings. — Plaster-of-Paris  Bandage. — Cover 
the  extremity  with  a  cotton  or  flannel  bandage  or  with  a 
woollen  stocking.  Take  a  gauze  roller  infiltrated  with  plaster 
and  place  it  endwise  in  a  basin  of  tepid  water,  the  water 
covering  the  plaster.  When  bubbles  cease  to  arise, 
squeeze  the  bandage  and  apply  it  ivitJiont  imich  tension, 
smoothing  out  each  turn  with  a  moistened  hand.     As  each 


PLASTIC  SURGERY.  759 

bandage  is  taken  from  the  basin  drop  a  fresh  one  into  the 
water.  Apply  four  thicknesses  of  bandage,  and  finish  the 
dressing  by  sprinkling  drj-  plaster  over  the  bandage  and 
smoothing  it  with  wet  hands.  The  ordinary-  plaster  will  set 
in  from  fifteen  to  thirty  minutes.  If  it  is  desired  to  have  it  set 
more  rapidly,  put  salt  or  alum  in  the  water ;  if  to  have  it  set 
more  slowly,  pour  stale  beer  into  the  water.  The  plaster 
bandage  is  removed  by  sawing  it  down  the  front  or  by 
moistening  with  dilute  hydrochloric  acid  and  then  cutting 
through  the  moistened  line  with  a  strong  knife.  Gigli  has 
devised  a  mode  of  application  which  enables  us  to  remove 
the  dressing  with  ease.  A  layer  of  cotton  is  placed  around 
the  limb.  A  piece  of  parchment  paper  which  has  been  wet  and 
shaken  out  is  placed  over  the  cotton.  A  cord  greased  with 
vaselin  is  laid  upon  the  paper  in  a  position  corresponding  to 
the  line  we  will  wish  to  saw  through  the  plaster.  Apply  the 
plaster  bandage  and  see  that  the  ends  of  the  cord  project 
beyond  the  bandage.  When  desiring  to  remove  the  band- 
age take  a  steel  wire,  make  nicks  on  one  side  of  it  by  means 
of  a  file,  and  attach  the  string  to  the  wire.  Pull  the  wire 
under  the  bandage.  Attach  each  end  of  the  wire  to  a 
wooden  handle  and  saw  through  the  plaster.^ 

Silicate-of-sodium  Dressing-. — Protect  the  part  as  is  done 
for  a  plaster  bandage.  Bandage  the  limb  loosely  with  an 
ordinary  gauze  bandage,  paint  this  bandage  with  silicate  of 
sodium,  apply  another  bandage  and  paint  it.  and  so  on  until 
six  layers  are  applied.  Gauze  bandages  soaked  in  silicate 
are  better  than  ordinary'  bandages.  Silicate  dressings  require 
from  twelve  to  eighteen  hours  to  dry,  and  they  are  removed 
by  softening  with  warm  water  and  then  cutting. 

XXXV.  PLASTIC  SURGERY. 

Plastic  surgery  includes  operations  for  the  repair  of  de- 
ficiencies, for  the  replacement  of  lost  parts,  for  the  restora- 
tion of  function  in  parts  tied  down  by  scars,  and  for  the  cor- 
rection of  disfiguring  projections.  A  plastic  operation  can 
be  successful  after  lupus  only  when  the  disease  has  been 
cured.  It  is  useless  to  do  a  plastic  operation  during  active 
syphilis,  and  a  plastic  operation  for  a  syphilitic  loss  of  sub- 
stance is  to  be  performed  only  after  the  patient  has  been 
thoroughly  treated  and  the  disease  has  been  apparently 
cured.  The  first  step  of  a  plastic  operation  consists  in  mak- 
ing raw  the  surfaces  which  are  to  be  brought  together ;  the 

^  La  Sdmairtc  MeJ.,  Nov.  3,  1S95. 


760  MODERN  SURGERY. 

second  step  is  the  complete  arrest  of  bleeding ;  the  third 
step  is  the  approximation  of  the  surfaces  without  tension ; 
the  fourth  step  is  to  close  any  gap  from  which  tissue  may 
have  been  transplanted ;  and  the  final  step  is  the  application 
of  the  dressings/     The  following  are  the  methods  used:^ 

Displacement  is  the  method  of  stretching  or  of  sliding  : 
(i)  approximation  after  freshening  the  edges  (as  in  hare- 
lip ;  (2)  sliding  into  position  after  transferring  tension  to 
other  locahties  (linear  incisions  to  allow  of  stretching  of 
the  skin  over  large  wounds).  Interpolation  is  the  method 
of  borrowing  material  from  an  adjacent  or  a  distant  region 
or  from  another  person  :  ( i )  transferring  a  flap  with  a 
pedicle,  which  flap  is  put  in  place  at  once  or  is  gradually 
gotten  into  place  by  a  series  of  partial  operations  (as  in 
rhinoplasty,  when  a  flap  is  transverse  from  the  forehead) ; 
(2)  transplanting  without  a  pedicle,  which  is  performed  by 
placing  in  position  and  by  fixing  there  portions  of  tissue 
recently  removed  from  the  part,  from  another  part  of  the 
same  individual,  or  from  a  lower  animal  (as  replacement  of 
the  button  of  bone  after  trephining,  transplanting  a  piece  of 
bone  from  a  lower  animal  to  remedy  a  bone-defect  in  a 
human  being,  or  the  grafting  of  a  piece  of  nerve  from  a  lower 
animal  or  an  amputated  human  limb  to  remedy  a  loss  of 
nerve  in  a  human  being  in  nerve-grafting,  or  skin-graft- 
ing). Retrenchment  is  the  removal  of  redundant  material 
and  the  production  of  cicatricial  contraction. 

Skin-grafting". — In  Reverdin's  method  the  surface  to 
be  grafted  should  possess  healthy  granulations  which  are  at 
the  skin-level.  The  grafts  should,  if  possible,  come  from  the 
person  to  be  grafted. 

Grafts  may  come  from  another  person  or  from  a  lower 
animal,  but  such  grafts  are  not  apt  to  grow,  and  even 
when  they  do  grow  fail  to  furnish  a  secure  cicatrix.  Frog- 
skin furnishes  unsatisfactory  grafts.  Arnot  has  employed 
the  lining  membrane  of  a  hen's  ^^'g,  cut  in  strips  and 
applied  upon  the  wound  with  the  shell-surface  upper- 
most. Lusk  has  blistered  the  skin  with  cantharides  and 
grafted  portions  of  the  epidermis.  In  order  to  graft  small 
fragments  of  human  epithelium,  cleanse  the  skin  from  which 
the  grafts  are  to  come,  the  ulcer,  and  the  skin  about  it,  and, 
if  corrosive  sublimate  is  used,  wash  it  away  with  a  stream 
of  warm  normal  salt  solution.  Thrust  a  sewing-needle 
under  the  epidermis  to  raise  it,  cut  off  the  graft  with  a  pair 
of  scissors,  and  place  the  cut  surface  of  the  graft  upon  the 

'  American  Text-book  of  Surgery.  ^  Ibid. 


PLASTIC  SURGERY.  76 1 

ulcer.  After  applying  a  number  of  grafts,  place  thin  pieces 
of  gutta-percha  tissue  over  the  grafts  and  extending  on  each 
side  of  the  ulcer,  and  so  placed  as  to  have  distinct  inter- 
vals between  them,  the  gaps  permitting  drainage.  This  tis- 
sue, after  being  asepticized,  is  moistened  with  warm  normal 
salt  solution  {^^  of  i  per  cent.).  Dress  with  a  pad  of  aseptic 
gauze  moistened  with  salt  solution  ;  place  over  this  gauze  a 
rubber-dam,  and  over  the  latter  absorbent  cotton  and  a 
bandage.  In  the  case  of  children  apply  a  light  silicate 
bandage.  Put  the  patient  in  bed.  In  forty-eight  hours  re- 
move all  the  dressings  e.xcept  the  gutta-percha  tissue,  irri- 
gate with  normal  salt  solution,  and  reapply  the  dressings. 
All  signs  of  the  grafts  will  often  have  disappeared.  In  a 
day  or  two,  at  the  site  of  grafting,  bluish-white  spots  should 
appear,  which  are  islands  of  epidermis.  Each  graft  is  capa- 
ble of  forming  about  half  an  inch  of  cicatrix.  Grafting  also 
stimulates  the  edges  of  the  ulcer  to  cicatrize  and  contract. 
At  the  end  of  seven  days  the  special  dressings  can  be  dis- 
pensed with.  The  spot  from  which  the  grafts  are  taken  is 
dressed  antiseptically.  Reverdin's  method  does  not  limit  cica- 
tricial contraction  to  any  great  degree,  and  the  new  skin  is 
apt  to   break  down. 

Thiersch's  Method. — Thoroughly  asepticize  the  ulcer,  the 
surrounding  skin,  and  the  site  from  which  the  graft  is  to 
come  (the  inner  side  of  the  arm  or  the  thigh),  and  wash 
away  the  mercurial  preparation  with  normal  salt  solution. 
Apply  dressings  wet  with  salt  solution.  On  bringing  the 
patient  into  the  operating-room  remove  the  dressings  from 
the  ulcer,  scrape  the  ulcer  and  its  edges,  irrigate  with  salt 
solution,  and  compress  to  arrest  hemorrhage.  Grafts  are  then 
obtained  by  putting  the  prepared  skin  upon  the  stretch  and 
cutting  strips  with  a  razor.  While  the  razor  is  being  used 
the  part  is  constantly  irrigated  with  salt  solution.  Mixter's 
apparatus  enables  one  to  perform  this  operation  with  great 
neatness  and  speed.  This  apparatus  consists  of  a  knife  and 
an  open  square  with  sharp  points  on  the  under  surface.  The 
square  is  forced  down  upon  the  front  of  the  thigh,  the  epi- 
dermis mounts  up  in  the  opening  to  above  the  level  of  the 
metal  sides,  and  the  grafts  may  be  cut  with  ease.  In  Hal- 
sted's  clinic  the  skin  of  the  thigh  is  made  tense  by  pressing 
upon  it  with  a  piece  of  asepticized  wood,  the  wood  is  drawn 
slowly  along,  and  is  followed  closely  by  the  sharp  catlin, 
with  which  the  surgeon  cuts  long  grafts.  The  grafts  are 
pressed  into  place,  and  each  graft  overlaps  a  little  the  edges 
of  the  wound  and  the  adjacent  grafts.     The  skin-wound  is 


762 


MODERN  SURGERY. 


dressed  antiseptically,  and  the  grafted  area  is  dressed  as  in 
Reverdin's  method.  Recently  it  has  been  suggested  that  a 
ring  of  aseptic  gauze  be  made  to  encircle  the  limb  below 
the  grafted  area,  and  another  ring  above  the  grafted  area;  on 
these  pads  little  strips  of  wood  wrapped  in  aseptic  gauze  are 
so  laid  as  to  make  a  cage,  and  around  this  cage  the  dressings 
are  appHed  (moist  chamber  plan). 


Fig.  2S0. — Mayer's  dressing  for  Thiersch's  method  of  skin-grafting  {Am.  Text-Book  of 

Surgery. 

Krause's  Method. — In  this  method  the  grafts  are  com- 
posed of  the  entire  thickness  of  the  skin.  The  ulcer  is  extir- 
pated and  asepticized  and  bleeding  is  arrested.  The  flap  is 
cut  one-sixth  larger  than  the  surface  to  be  covered.  Fat  is 
kept  out  of  the  graft.  The  bit  of  tissue  is  laid  upon  the  ulcer, 
the  edges  of  the  graft  being  brought  against  the  edges  of  the 


Fig.  281. — Indian  method  of  rhinoplasty.  Fig.  282, — Italian  method  of  rhinoplasty. 

ulcer.     It  is  not  necessary  to  employ  sutures.     The  part  is 
dressed  in  a  moist  chamber.    If  the  graft  perishes,  remove  it. 


DISEASES   OF  GENITO-URINARY  ORGANS.  763 

Rhinoplasty. — The  complete  operation  may  be  per- 
formed by  transferring  a  flap  from  the  forehead.  This  is 
known  as  the  Indian  operation.  The  edges  of  the  defect  are 
made  raw.  A  model  of  the  desired  nose  is  made  out  of  gutta- 
percha, and  its  outlines  are  marked  upon  the  forehead,  and 
the  cut  is  made  one-quarter  of  an  inch  outside  of  the  out- 
line so  as  to  allow  room  for  retraction.  The  flap  is  turned 
down  and  sutured  in  place  (Fig.  281),  care  being  taken  not 
to  cut  off  the  blood-supply  in  the  pedicle.  Plugs  of  gauze 
or  tubes  are  inserted  to  support  the  flap. 

The  complete  operation  can  be  performed  by  the  Italian 
method  (Tagliacotian  method).  In  this  method  the  flap  is 
marked  out  on  the  arm,  and  is  made  twice  the  size  of  the 
desired  nose,  and  the  flap  is  left  attached  by  a  broad  pedicle. 
The  nasal  defect  is  sewed,  and  the  flap  is  sutured  in  place, 
the  hand  being  held  upon  the  head  by  a  special  apparatus 
(Fig.  282).  The  raw  surface  upon  the  arm  is  dressed.  In 
about  three  weeks  the  flap  is  cut  loose  from  the  arm,  and  is 
pared  and  corrected  as  may  be  necessary. 

The  operations  for  harelip  and  cleft  palate,  and  plastic 
operations  on  muscles,  nerves,  tendons,  and  bones,  are 
considered  in  other  portions  of  the  work. 

XXXVI.    DISEASES   AND   INJURIES  OF  THE  GENITO- 
URINARY  ORGANS. 

Hematuria. — By  this  term  is  meant  the  voiding  of 
bloody  urine  or  pure  blood,  the  blood  arising  from  any  por- 
tion of  the  urinary  apparatus,  and  the  condition  being  a 
symptom  and  not  a  disease.  Hematuria  may  be  a  symptom 
of  disease  or  of  injury  of  some  part  of  the  urinary  system, 
of  blood-disorganizations  (purpura,  scurvy,  or  variola),  or  of 
metallic  poisoning  (mercury,  lead,  or  arsenic).  The  color  of 
the  urine  in  hematuria  may  be  anything  between  a  light  red 
and  a  decided  black,  but  these  colors  may  be  produced  by 
agents  other  than  blood.  Senna  and  rhubarb  make  urine 
red ;  carbolic  and  salicylic  acids,  brown ;  beet-root  and 
sorrel,  the  color  of  blood ;  methylene-blue,  blue.  In  jaun- 
dice, melanosis,  and  splenic  fever  the  urine  becomes  brown. 
Be  sure  that  bloody  urine  in  the  female  is  not  due  to  admix- 
ture with  menstrual  blood. 

Tests  for  Blood. — Spectroscope  Test. — Fresh  urine 
diluted  with  water  shows  the  two  absorption-bands  of  oxy- 
hemoglobin. The  addition  of  ammonium  sulphid  causes 
the  two  bands  to  give  place  to  the  band  of  reduced  hemo- 


764  MODERN  SURGERY. 

globin.  If  bloody  urine  stands  for  some  time,  the  four  bands 
of  methemoglobin  are  discovered  (v.  Jaksch), 

Heller's  Test. — Add  potassium  hydrate  to  the  urine,  and 
boil :  a  red  precipitate  of  earthy  phosphates  and  hematin 
forms.  Throw  the  precipitate  upon  a  filter  and  treat  with 
acetic  acid :  a  red  solution  is  produced,  which  soon  fades. 

Rosenthal's  Test. — Take  the  precipitate  from  caustic  pot- 
ash, dry  it,  and  test  it  for  hematin ;  put  some  of  the  dry 
sediment  on  a  slide,  add  a  crystal  of  common  salt,  apply  a 
cover-glass,  and  cause  a  few  drops  of  glacial  acetic  acid  to 
flow  under  the  glass ;  warm,  but  do  not  boil.  Teichmann's 
crystals  will  appear  on  cooling. 

Struve's  Test. — Test  the  urine  with  hydrate  of  potassium^ 
and  add  acetic  acid  in  excess :  a  dark  precipitate  forms, 
which  will  yield  crystals  of  hematin  when  treated  with  sal 
ammoniac  and  glacial  acetic  acid. 

Almen's  Test. — Take  10  c.c.  of  urine,  and  pour  upon  its 
surface  a  mixture  of  equal  parts  of  tincture  of  guaiac  and 
old  oil  of  turpentine :  at  the  point  of  junction  of  this  fluid 
with  the  urine  there  forms  a  white  ring  which  turns  blue. 

Microscope  Test. — The  microscope  shows  numerous  cor- 
puscles except  in  a  very  alkaline  urine,  when  but  few  cor- 
puscles may  be  found. 

In  hemoglobinuria — a  condition  sometimes  occurring  in 
burns,  acute  maladies,  and  metallic  poisoning — there  is  pres- 
ent blood-coloring  matter,  which  is  shown  by  Heller's  test 
and  by  Almen's  test.  The  spectroscope  shows  methemo- 
globin. The  microscope  shows  no  corpuscles  or  only  a  few^ 
but  discloses  masses  of  pigment. 

Bleeding:  from  the  Kidney-substance. — Bleeding 
from  the  pelvis  of  the  kidney  and  from  the  ureter  may  be  due 
to  inflammation,  congestion,  contusion,  stone,  vicarious  men- 
struation, hemorrhagic  diathesis,  powerful  diuretics,  fevers, 
purpura,  tumors,  catheterization  of  the  bladder,  etc.  Blood 
is  thoroughly  mixed  with  the  urine,  and  no  sediment  forms 
(smoky  urine).  The  corpuscles  are  profoundly  altered,  are 
devoid  of  coloring-matter,  and  show  pale-yellow  rings.  The 
severity  of  the  hemorrhage  is  measured  by  the  number  of 
the  corpuscles.  Von  Jaksch  states  that  the  diagnosis 
between  renal  and  ureteral  hemorrhage  rests  on  the  nature 
of  the  casts  and  the  epithelium  present.  From  the  pelvis 
of  the  kidney  and  from  the  ureter  come  small  epitheHum, 
the  cells  from  the  superficial  layers  being  polygonal  or 
elliptical,  those  from  the  deeper  layers  being  oval  or  irregu- 
lar.    In  hemorrhage  from  the  ureter  the  cells  are  few;  in 


DISEASES   OF  GENITOURINARY  ORGANS.  765 

hemorrhage  from  the  pelvis  they  are  plentiful  and  rest  upon 
one  another  like  "  tiles  on  a  roof "  (v.  Jaksch).  Cells  from 
the  tubules  of  the  kidney  are  small,  granular,  and  polyhedral, 
have  large  nuclei,  and  are  often  so  arranged  as  to  form 
cylinders  (epithelial  casts).  The  urine  of  renal  hemorrhage 
is  apt  to  be  acid  unless  alkalies  have  been  administered, 
unless  the  bleeding  has  been  severe,  or  unless  pus  is  present 
in  the  urine.  A  very  large  renal  hemorrhage  may  cause  the 
passage  of  almost  pure  blood.  In  renal  hematuria  there 
are  aching  in  the  loin,  numbness  of  the  corresponding  leg, 
and  often  renal  colic.  The  use  of  the  cystoscope  enables  the 
surgeon  to  determine  if  the  hemorrhage  is  vesical  or  renal, 
and  if  it  comes  from  one  or  both  kidneys.  If  the  bladder- 
fluid  is  kept  clear,  the  blood  can  be  seen  flowing  out  of  the 
ureter  of  the  damaged  organ. 

Catheterization  of  the  ureters  may  give  valuable  informa- 
tion.    Kelly  performs   this    operation  in  women   with   the 


Fig.  283. — Nitze's  instrument  in  use  (Berl.  klin.  Wochen.). 

greatest  ease.  Aseptic  precautions  are  observed.  A  specu- 
lum is  inserted,  the  orifice  of  the  ureter  is  cleansed  with  a 
bit  of  cotton,  and  the  catheter  is  inserted,  and  the  urine  is 
collected  in  a  sterile  test-tube.  Kelly's  catheter  is  of  flexible 
5ilk,  30  cm.  in  length,  2  mm.  in  diameter,  with  a  blunt  coni- 


766   .  MODERN  SURGERY. 

cal  end  and  an  oval  eye.  The  catheter  is  pushed  into 
the  ureter  12  or  15  mm.  The  rate  of  flow  in  a  given  time 
proves  the  competence  of  the  kidney.  The  male  ureter 
can  be  catheterized  by  means  of  the  instrument  of  Nitze 
(Fig.  283). 

Kelly  has  recently  catheterized  the  ureter  in  a  man  by  in- 
serting a  straight  speculum,  placing  the  patient  in  the  knee- 
chest  position  to  inflate  the  bladder  with  air,  and  introducing 
a  metallic  catheter. 

Vesical  hemorrhage,  including  hemorrhage  from 
the  prostate,  may  follow  the  relief  of  retention  of  urine, 
may  be  due  to  stone,  inflammation,  tumor,  etc.,  or  may  arise 
from  traumatisms,  instrumental  or  otherwise.  The  color  of 
the  urine  is  usually  bright  red,  but  if  long  retained  in  the 
bladder  it  becomes  black  and  often  tarry.  The  reaction  is 
alkaline.  The  clots,  when  floated  out,  are  large  and  without 
definite  shape.  In  micturition  the  urine  is  clear  or  only  a 
little  colored  at  the  beginning,  but  becomes  darker  and  darker 
as  micturition  ends,  at  which  time  the  flow  may  consist  of 
almost  pure  blood.  In  very  small  vesical  hemorrhages  the 
urine  may  be  smoky.  Crystals  of  triple  phosphate  indicate 
bladder  disorder.  The  microscope  shows  colorless  and 
swollen  corpuscles  and  many  polygonal  cells.  Symptoms 
of  bladder  mischief  usually  exist,  but  cystoscopic  examina- 
tions or  exploratory  suprapubic  cystotomy  may  be  demanded 
for  the  diagnosis. 

Urethral  Hemorrhage. — In  urethral  bleeding  blood 
comes  independently  of  micturition,  or  blood  comes  out  first 
and  is  followed  by  clear  urine.  Urethral  hemorrhage  arises 
from  an  acute  urethritis,  from  an  inflamed  stricture,  from  the 
passage  of  an  instrument,  or  from  some  other  traumatism. 

The  source  of  urethral  hemorrhage  can  be  ascertained  \yy 
the  use  of  the  endoscope. 

Pain  in  Genito-urinary  Diseases. — Pain  as  a  symp- 
tom of  genito-urinary  disease  may  be  found  at  some  point 
distant  from  the  seat  of  lesion.  A  stone  in  the  bladder 
causes  pain  in  the  head  of  the  penis  just  back  of  the  meatus  - 
stone  in  the  kidney  induces  pain  in  the  loin,  the  groin,  the 
thigh,  and  the  testicle ;  inflammation  of  the  testicle  causes 
pain  in  the  line  of  the  cord  in  the  groin.  In  other  cases  of 
genito-urinary  disease  pain  is  felt  at  the  seat  of  lesion,  as  in 
urethritis  and  prostatitis.  Pain  felt  before  micturition,  and 
being  relieved  by  the  act,  is  found  in  cystitis  and  in  retention 
of  urine.  Pain  is  felt  during  micturition  in  inflammation  of 
the  bladder,  prostate,  and  urethra,  and  in  the  passage  of 


DISEASES   OF  GENITO-URINARY  ORGANS.  jdj 

gravel  or  stone.  Pain  which  is  acute  at  the  end  of  micturi- 
tion is  noted  in  stone  in  the  bladder,  in  inflammation  of  the 
neck  of  the  bladder,  and  in  inflammation  of  the  prostate 
gland.  The  pain  of  stone  in  the  bladder,  it  may  be  observed, 
is  ameliorated  by  rest  and  is  aggravated  by  exercise.  The 
pain  of  acute  prostatitis  is  intensified  by  defecation. 

Frequency  of  Micturition.  —  Frequent  micturition 
arises  from  irritation  of  the  sensory  nerves,  from  phimosis, 
contracted  meatus,  inflammations,  very  acid  urine,  calculi, 
urethral  stricture,  and  hyperesthesia  of  the  urethra.  Fre- 
quency of  micturition  may  be  due  to  spinal  irritability  from 
concussion  or  from  sexual  excess,  from  contraction  of  the 
bladder  rendering  the  viscus  unable  to  hold  much,  from 
worry,  anxiety,  fear,  or  from  excessive  urinary  secretion,  as 
in  diabetes  or  in  the  first  stage  of  contracted  kidney.  Fre- 
quent micturition  exists  in  obstruction  by  enlarged  prostate 
and  in  atony  of  the  bladder-walls.  Hypersecretion  of  urine 
plus  bladder  intolerance  is  known  as  "  nervousness,"  and  is 
found  in  hysteria.  Frequency  of  micturition  increased  by 
inovcineiit  is  observed  in  stone  and  tumor  of  the  bladder ; 
increased  by  rest,  is  found  in  enlarged  prostate  and  atony  of 
the  muscular  walls  of  the  viscus.  Frequency  of  micturition 
with  diminution  of  stream-caliber  suggests  a  constriction  of 
the  urethral  diameter ;  frequency  of  micturition  with  dimin- 
ished force  suggests  a  posterior  stricture,  enlarged  prostate, 
or  bladder  atony.  Slowness  of  micturition  hints  at  enlarged 
prostate,  atony,  or  urethral  stricture. 

Thompson' s  diagnostic  questions  are  as  follows  : 

"  I.  Have  you  any,  and,  if  so,  what,  frequency  in  passing 
water  ?  Is  frequency  more  manifest  during  the  night  or  the 
day  ?  Is  frequency  more  manifest  during  motion  or  rest  ? 
Does  any  other  circumstance  affect  it  ? 

"  2.  Is  there  pain  on  passing  urine,  and,  if  so,  is  it  before, 
during,  or  after  the  act  ?  What  is  its  character — acute, 
smarting,  dull,  transitory,  or  continuous  ?  What  is  its  seat  ? 
Is  it  felt  at  other  times,  and  is  it  produced  or  intensified  by 
sudden  movements  ? 

"  3.  What  is  the  character  of  the  stream  ?  Is  it  small  or 
large  ;  twisted  or  irregular  ;  strong  or  weak  ;  continuous,  re- 
mitting, or  intermitting  ?  Does  it  come  by  the  meatus,  or 
partly  or  entirely  through  fistulae  ? 

"  4.  Is  the  character  of  the  urine  altered  ?  What  is  its 
appearance,  color,  odor,  reaction,  and  specific  gravity  ?  Is 
it  clear  or  turbid,  and,  if  turbid,  is  it  so  at  the  time  of  pass- 
ing ?     Does  it  vary  in  quantity  ?     Are  the  normal  constitu- 


^68  MODERN  SURGERY. 

ents  increased  or  diminished?  Does  it  contain  abnormal 
elements,  as  albumin  or  sugar?  What  inorganic  deposits 
are  found  ?     What  organic  materials  are  met  with  ? 

"5.  Has  the  urine  ever  contained  blood?  If  so,  was 
the  color  brown  or  bright  red;  were  the  blood  and  urine 
thoroughly  mixed ;  was  the  blood  passed  at  the  end  or  at 
the  beginning  of  micturition,  or  did  it  come  only  with  the 
last  drops  of  urine ;  or  was  it  passed  independently  of 
micturition  ? 

"  6.  Inquire  as  to  pain  in  the  back,  loins,  and  hips,  perma- 
nent or  transitory,  and  for  the  occurrence  of  severe  parox- 
ysms of  pain  in  these  regions." 

Diseases  and  Injuries  of  the  Kidney  and  Ureter. 

Tumors  of  the  Kidney. — Tumors,  innocent  or  malig- 
nant, may  arise  in  the  kidney.  Among  the  innocent  tumors 
are  fibroma,  lipoma,  angeioma,  and  adenoma.  A  mahgnant 
tumor  may  be  either  sarcoma  or  carcinoma.  Sarcoma  is 
most  common  in  the  young,  and  may  reach  an  enormous 
size.  A  malignant  tumor  of  the  kidney  produces  hema- 
turia, the  urine  often  containing  blood-casts  of  the  ureter, 
kidney,  and  pelvis  (Osier),  and  sometimes,  though  rarely, 
characteristic  cells.  Pain  is  often  present  in  the  loin  and 
thigh,  and  there  may  be  colic-like  attacks  when  clots  are 
passing  through  the  ureter.  Emaciation  is  rapid  and  pro- 
nounced. A  tumor  can  usually  be  detected.  The  only 
possible  treatment  is  early  nephrectomy.  In  some  few 
cases  an  innocent  tumor  can  be  removed  by  a  partial  neph- 
rectomy. A  malignant  tumor  requires  a  complete  neph- 
rectomy. In  making  a  diagnosis  of  renal  tumor  use  the 
cystoscopy  If  blood  is  coming  from  a  ureter,  note  if  it  is 
from  only  one  or  from  both.  Blood  from  both  would  con- 
traindicate  nephrectomy.  Before  removing  a  kidney  it  is 
well  to  be  sure  that  the  patient  is  possessed  of  two  kidneys. 
Note  if  urine  flows  from  each  ureter,  or,  if  uncertain,  cathe- 
terize  the  ureters  or  have  a  specialist  do  it. 

Mobile  Kidney. — There  are  two  forms  of  this  condition  : 
( I )  movable  kidney,  which  is  an  organ  freely  moving  back  of 
the  peritoneum,  either  within  the  cavity  of  its  fibrofatty  cap- 
sule or  entirely  without  its  capsule  (this  condition  is  ac- 
quired) ;  and  (2)  floating  or  zvandering  kidney,  an  organ 
having  a  mesonephron  and  lying  within  the  peritoneal 
cavity  (this  rare  condition  is  always  congenital).  Keen 
states  that  there  may  be  drawn  a  clear  theoretical  distinction 


DISEASES   OF  GENITO-URINARY  ORGANS.  769 

between  movable  and  floating  kidney,  but  practically  there 
is  no  rigid  line  of  demarcation,  as  a  movable  kidney  may 
have  as  large  a  range  of  movement  as  a  floating  kidney. 
When  a  movable  kidney  becomes  fixed  in  an  abnormal 
situation  the  organ  is  spoken  of  as  dislocated.  The  organ 
may  drop  below  the  brim  of  the  pelvis,  may  cross  the  verte- 
bral column,  or  may  reach  the  anterior  abdominal  wall. 
Women  more  often  suffer  from  movable  kidney  than  do 
men,  and  it  is  found  in  the  great  majority  of  cases  upon 
the  right  side.  Floating  kidney  is  always  congenital. 
Among  the  assigned  causes  of  the  movable  condition  are 
to  be  named  traumatisms,  strains,  abdominal-wall  laxity 
from  pregnancy,  absorption  of  peritoneal  fat  from  wasting 
disease  (Edebohls),  and  tight  lacing. 

Symptoms  of  Both  Forms. — There  may  be  no  discomfort 
whatever,  or  the  patient  may  be  a  confirmed  invalid.  The 
usual  symptoms  are  epigastric  pain  (just  to  the  left  of  the 
middle  line),  which  disappears  when  the  kidney  is  replaced, 
dragging  pain  in  the  loin,  and  paroxysms  like  nephritic  colic. 
There  is  a  sense  of  a  moving  body  in  the  abdomen,  and  the 
patient  has  aggravated  indigestion,  often  accompanied  by 
vomiting.  Constipation  is  the  rule,  and  violent  attacks  of 
cardiac  palpitation  are  common.  Most  subjects  of  this 
kidney-mobility  are  extremely  nervous,  many  of  them  hys- 
terical or  hypochondriacal.  In  women  the  sexual  organs 
are  almost  invariably  deranged,  and  menstruation  aggravates 
the  pain  and  discomfort.  All  the  symptoms  are  intensified 
by  exertion  and  are  modified  by  rest.  The  urine  is  normal. 
The  proof  of  the  existence  of  movable  kidney  is  the  finding 
of  a  tumor  (movable  on  respiration,  change  of  position,  and 
palpation)  shaped  like  that  organ,  pressure  upon  which  oc- 
casions no  sensation  or  causes  pain  or  a  sickening  feeling. 
A  "  lumbar  recess  "  (Morris)  may  be  found,  and  percussion 
over  the  loin  gives  resonance.  In  some  cases  a  movable 
kidney  can  be  readily  detected  when  the  patient  stands  up, 
but  is  hard  to  find  when  he  is  recumbent.  Franks's  method 
of  examination  is  very  satisfactory.  The  patient  is  placed 
recumbent.  If  dealing  with  a  right  kidney,  the  surgeon 
stands  to  the  right  side  and  pushes  four  fingers  of  his  left 
hand  in  the  loin  below  the  twelfth  rib,  and  rests  the  thumb 
lightly  in  front  just  below  the  ribs.  The  patient  takes  a  full 
breath  and  holds  it  a  moment,  and  just  before  he  empties 
his  lungs  the  surgeon  presses  his  thumb  up  deeply  below 
the  ribs.  During  expiration  the  thumb  follows  the  liver, 
and  the  fingers  press  toward  the  front.  If  with  the  right 
49 


770  MODERN  SURGERY. 

hand  the  kidney  can  be  felt  entirely  below  the  left  hand,  the 
case  is  one  of  movable  kidney.  If  such  a  condition  is  de- 
tected, press  hard  with  the  right  hand,  and  gradually  loosen 
the  grasp  of  the  left  hand,  and  the  kidney  will  shp  between 
the  fingers  and  ascend.  A  normally  mobile  kidney  descends 
so  that  its  lower  half  can  be  felt,  but  it  moves  back  during 
expiration.^  A  movable  kidney  must  not  be  mistaken  for 
a  distended  gall-bladder,  a  tumor  of  the  mesentery,  stomach, 
or  omentum,  a  phantom  tumor,  an  ovarian  tumor,  or  a  can- 
cer of  the  pancreas.  Sometimes  a  movable  kidney  endan- 
gers life,  rupture  of  the  kidney  or  twisting  or  rupture  of  the 
ureter  occurring,  the  ultimate  cause  of  death  being  albumi- 
nuria, uremia,  or  hydronephrosis. 

Treatment. — Mobile  kidney  is  treated  as  follows  :  (i)  The 
rest-treatment  of  Weir  Mitchell  may  be  tried ;  it  often  markedly 
mitigates  the  symptoms,  but  does  not  seem  to  cure.  (2) 
Bandage  and  pad  should  always  be  tried,  using  the  pad  of 
Dunning  or  Newman :  this  will  cure  not  a  few  cases. 
Edebohls  uses  only  a  bandage  of  elastic  webbing  or  a  well- 
fitting  corset.  (3)  Nephrorrhaphy  is  the  proper  procedure 
in  most  instances  (page  783).  It  is  the  author's  experience 
that  if  the  patient  has  had  marked  nervous  symptoms  for  a  long 
time,  nephrorrhaphy  will  rarely  cause  them  to  permanently 
pass  away,  even  though  the  kidney  remains  firmly  anchored. 
(4)  Nephrectomy  is  necessary  only  in  very  rare  cases ;  it  may 
be  done  for  dislocated  kidney,  when  kidney  disease  exists, 
or  when  nephrorrhaphy  has  failed  in  a  case  of  great  severity. 

Injuries  of  the  Kidney. — Laceration  or  rupture  is 
caused  by  falls  and  by  blows  upon  the  back  or  the  belly. 
The  blood  may  or  may  not  extravasate  into  surrounding 
structures.  The  symptojns  are  pain  in  the  loin,  shooting 
into  the  testicle  or  the  thigh  ;  frequent  and  painful  passage 
of  bloody  urine  or  suppression  of  urine ;  the  loin  is  full  and 
is  dull  on  percussion,  and  collapse  or  evidences  of  internal 
hemorrhage  exist.  Bloody  urine  is  not  proof  of  renal  injury, 
and  kidney  damage  may  occur  without  hematuria.  The  use 
of  the  cystoscope  or  catheterization  of  the  ureters  will  show 
from  which  kidney  blood  comes. 

Treatment. — If  the  shock  is  profound  with  increasing  ful- 
ness of  the  loin,  whether  hematuria  exists  or  not,  or  if  blood 
comes  profusely  from  the  urethra,  make  an  exploratory 
lumbar  incision  and  stop  the  bleeding  by  packing,  or  by  a 
purse-string  suture  (Figs.  284,  285),  or,  if  necessary,  perform 
partial,  or  even  complete,  nephrectomy.    Ordinarily  the  cases 

^  British  Med.  Journ.,  Oct.  12,  1895. 


DISEASES   OF  GENITO-URINARY  ORGANS.  77 1 

are  treated  by  rest  in  bed  and  by  feeding  with  liquid  food  or  by 
nutritive  enemata  to  prevent  vomiting.  Opium,  tannic  acid,  or 
gallic  acid  may  be  used.    Apply  ice-bags  to  the  loin  and  the 


FiCf.  284. — "  Purse-string"  suture  applied  to  a  perforation  (after  Schachner). 

side  of  the  abdomen,  and  after  bleeding  ceases  strap  the  loin 
and  apply  a  binder.  If  large  blood-clots  cause  pain  or  reten- 
tion, introduce  a  catheter  and  inject  the  bladder  with  boric 


Fig.  285. — Showing  the  application  of  a   double  "purse-string"  suture   for  the   arrest   of 
hemorrhage  in  large  wound  (after  Schachner). 

acid,  or  use  the  tube  and  evacuator  of  a  Bigelow  apparatus. 
If  this  procedure  fails,  open  the  bladder  by  a  suprapubic 
incision  and  drain. 

Perforating  wounds  of  the  kidney,  if  purely  posterior,  do 
not  involve  the  peritoneum  ;  if  anterior,  they  do.  The  symp- 
toms are  escape  of  blood  and  urine  by  the  wound;  hematuria 
is  usual,  but  not  invariable ;  pain  as  in  rupture  ;  the  patient 
may  be  unable  to  micturate  ;  and  nausea,  vomiting,  and  con- 
stitutional signs  of  hemorrhage  exist.  Traumatic  peritonitis, 
perinephric  abscess,  or  general  sepsis  may  ensue.     Confirm 


'jyz  MODERN  SURGERY. 

the  diagnosis  by  exploration  with  the  finger.  Extraperi- 
toneal injuries  give  a  good,  and  intraperitoneal  a  bad, 
prognosis. 

Treatment. — If  the  wound  in  perforated  kidney  is  extra- 
peritoneal, enlarge  it  to  permit  of  drainage,  and  arrest  hem- 
orrhage by  packing  and  hot  water,  or  by  a  purse-string  suture 
(Figs.  284,  285).  Asepticize  the  wound,  insert  a  drainage- 
tube  down  to  the  kidney,  dress  often  with  bichlorid  gauze, 
keep  the  patient  in  bed  on  a  low  diet,  and  give  gallic  acid 
and  opium.  In  some  cases  nephrectomy,  partial  or  complete, 
will  be  required.  In  intraperitoneal  wounds  perform  an 
abdominal  section  and  remove  the  damaged  organ  (see 
Nephrectomy). 

Wotinds  of  the  Ureter. — The  ureter  may  be  wounded 
by  the  surgeon  accidentally  during  the  performance  of  an 
abdominal  operation,  or  it  may  be  wounded  intentionally,  as 
in  Morris's  cases,  in  Avhich  a  malignant  growth  was  incorpo- 
rated with  the  ureter.  Wounds  of  the  ureter  as  a  result  of 
accidental  violence  are  almost  invariably  associated  with  other 
serious  injuries. 

Treatment. — Remember  that  the  upper  three-fourths  of 
the  ureter  can  be  reached  by  an  extraperitoneal  incision, 
which  is  a  prolongation  of  the  incision  for  lumbar  nephrec- 
tomy, running  from  the  twelfth  rib  downward,  and  forward 
to  one  inch  anterior  to  the  spine  of  the  ilium,  and  then 
parallel  to  Poupart's  ligament  until  a  point  is  reached  above 
its  middle  (Fenger).  The  lower  one-fourth  of  the  ureter  can 
be  reached  by  abdominal  section  or  by  sacral  resection 
(Cabot).  If  it  seems  probable  that  the  ureter  is  wounded  or 
ruptured  explore,  and  if  this  is  found  to  be  the  case  en- 
deavor to  restore  the  continuity  of  the  tube  (Fenger).  If  the 
ureter  is  cut  across  near  the  bladder,  implant  the  proximal 
end  into  the  bladder  (Van  Hook,  Penrose,  Kelly).  If  it  is 
cut  above  the  bladder  portion,  perform  lateral  implantation 
by  Van  Hook's  method  (page  784). 

A  longitudinal  wound  of  the  urethra  inflicted  during  an 
abdominal  operation  should  be  sutured,  but  if  the  duct  can- 
not be  readily  reached,  simply  make  a  posterior  incision  and 
drain,  as  the  longitudinal  wound  will  heal  by  granulation  if 
no  sutures  are  inserted  (Van  Hook). 

Renal  Calculus. — A  stone  in  the  kidney  is  formed  by 
the  precipitation  of  urinary  salts  into  the  renal  epithelial  cells 
and  the  gluing  together  of  these  salts  and  cells  by  material 
from  mucus  or  blood-clot,  this  mass  serving  as  a  nucleus 
on  which  accretion  takes  place.     Most  calculi  escape  when 


DISEASES   OF  GENITO-URINARY  ORGANS.  773 

small  as  gravel.  The  cause  is  a  highly  acid  urine,  which 
induces  catarrh  of  the  renal  tubes.  This  high  concentration 
of  urine  is  favored  by  a  sedentary  life,  by  the  ingestion  of 
much  alcohol  or  nitrogenous  food,  by  constipation,  by  an 
inactive  skin,  and  by  a  torpid  liver.  The  children  of  poverty 
are  liable  to  calculi  because  of  the  use  of  unsuitable  foods 
and  the  formation  of  great  amounts  of  nitrogenous  waste. 
Males  more  often  suffer  than  do  females,  certain  locations 
favor  the  development  of  the  malady,  and  a  family  tendency 
sometimes  exists. 

Symptoms. — The  symptoms  of  stone  in  the  kidney  may 
not  appear  for  years,  but  generally  they  are  manifested  early. 
The  patient  usually  complains  of  pain  in  the  loin,  and  some- 
times of  pain  in  the  iliac  region.  Deep  percussion  over  the 
kidney  causes  pain  in  the  loin,  even  when  pressure  is  pain- 
less (Jordan  Lloyd's  symptom).  Pain  is  aggravated  by  exer- 
cise. The  urine  is  often  somewhat  albuminous,  and  may 
from  time  to  time  contain  blood.  Frequency  of  micturition  is 
noted  during  the  day,  but  not  at  night.  The  urine  may  be 
purulent.  Nephritic  colic  is  due  to  the  washing  of  a  calculus 
into  the  orifice  of  the  ureter,  which  it  blocks,  tears,  or  dis- 
tends. The  pain  is  either  sudden  or  gradual  in  onset,  is  fearful 
in  intensity,  and  runs  from  the  lumbar  region  down  the  cor- 
responding thigh  and  spermatic  cord  (the  testicle  being 
retracted)  and  into  the  abdomen  and  shoulder-blade.  There 
are  nausea,  vomiting,  collapse,  sometimes  unconsciousness  or 
convulsions.  Frequent  attempts  at  making  w^ater  are  pro- 
ductive of  pain,  but  of  little  urine.  The  urine  is  usually,  but 
not  always,  smoky  from  blood.  After  a  time  the  pain 
vanishes,  the  stone  having  passed  into  the  bladder  or  having 
fallen  back  into  the  pelvis  of  the  kidney.  A  calculus  retained 
in  the  kidney  eventually'excites  pyelitis.  There  is  pus  in 
the  urine,  and  soreness  or  pain  in  the  loin  exists.  Kelly 
says :  even  if  pus  is  found  we  are  not  always  sure  from 
which  kidney  it  came.  Pain  or  sweUing  may  point  to  one 
side,  but  we  are  not  sure  that  the  other  organ  is  not  also 
affected.  If  able  to  pass  the  renal  catheter  into  one  ureter, 
attach  a  syringe,  and  by  making  suction  draw  out  any  pus 
which  may  be  present.  In  renal  calculi  cases  this  fluid  is 
apt  to  contain  fragments  of  uric  acid.  By  using  a  renal 
bougie  coated  with  dental  wax  it  may  be  possible  to  make 
scratches  on  the  instrument  when  it  comes  in  contact  with  a 
concretion.'  Slight  attacks  of  colic  occur  from  the  passage 
of  small  stones  or  of  plugs  of  mucus.     When  a  stone  is  im- 

1  Howard  Kelly,  in  Med.  News,  Nov.  30,  1895. 


774  MODERN  SURGERY. 

pacted  in  the  pelvis  the  point  of  greatest  tenderness  on  press- 
ure is  below  the  last  rib,  by  the  edge  of  the  erector  spinae 
muscle.  When  a  stone  is  impacted  in  the  ureter  the  point  of 
greatest  tenderness  is  either  in  the  loin  below  the  level  of  the 
kidney  or  in  the  iliac  region  (Perkins).  In  many  cases  a 
stone  in  the  kidney  or  ureter  can  be  skiagraphed.  If  a 
stone  partly  obstructs  the  ureter,  the  urine  is  pale  and  of 
low  specific  gravity  and  free  from  albumin.  Jordan  Lloyd 
says  that  impaction  near  the  bladder  causes  symptoms  sim- 
ilar to  stone  in  the  bladder.  Impaction  near  the  kidney  is 
accompanied  by  hematuria  and  pyuria.  In  stone  in  the 
ureter  prodding  the  loin  does  not  cause  pain  (Lloyd). 
Entire  obstruction  of  the  ureter  induces  hydronephrosis  or 
pyonephrosis.  Nephrolithiasis  may  cause  death  by  ex- 
haustion, by  sepsis,  by  rupture  of  a  hydronephrosis,  or  by 
amyloid  degeneration. 

Treatment. — For  the  gravel  of  the  uric-acid  diathesis  use 
alkalies,  especially  the  liquor  potassii  citratis,  and  reduce  the 
amount  of  nitrogen  in  the  diet  to  a  minimum,  at  the  same 
time  washing  out  the  organs  by  copious  draughts  of  Poland 
water  or  Londonderry  lithia.  Piperazin,  in  doses  of  gr. 
v  to  gr.  viij  three  times  a  day,  is  highly  commended.  Exer- 
cise is  to  be  insisted  on.  When  gravel  is  phosphatic  order 
strychnin,  the  mineral  acids,  and  rest  at  the  seaside.  When 
oxalate  of  lime  is  found  restrict  diet,  use  the  mineral  acids, 
recommend  travel  or  rest  amid  new  surroundings,  and  give 
an  occasional  course  of  sodii  phosphas,  ^ss  three  times  a  day, 
drunk  in  Buffalo  lithia  water.  Nephritic  colic  is  relieved  by 
hypodermatic  injection  of  morphin  and  atropin,  the  hot  bath, 
diluent  drinks,  or  the  inhalation  of  ether.  After  the  attack 
wash  out  the  bladder  with  an  evacuator.  If  a  stone  impacts 
in  the  ureter,  perform  the  operation  of  ureterolithotomy. 
The  diagnosis  of  this  impaction  is  often  possible  only  by 
exploratory  laparotomy.  If  the  symptoms  point  to  stone  in 
the  kidney,  medical  treatment  having  been  used  without 
avail,  and  there  being  no  evidence  of  organic  disease  of  the 
other  kidney,  make  an  exploratory  lumbar  incision ;  feel  the 
surface  of  the  kidney  with  the  finger,  sound  the  inside  of  the 
organ  with  a  needle,  and  if  a  stone  is  detected,  incise  the 
kidney  and  remove  the  stone.  Keen  is  of  the  opinion  that 
operation  should  not  be  performed  if  the  urea  is  below  i  per 
cent.  If,  after  nephrolithotomy,  suppression  of  urine  occurs, 
cut  into  the  other  kidney,  as  in  half  of  all  cases  a  stone  will 
be  found  lodged  there. 

Abscess  of  the  kidney  is  caused  by  traumatism,  by 


DISEASES    OF  GENITO-URINARY  ORGANS.  775 

calculus,  by  stricture  of  the  urethra,  by  disease  of  the  blad- 
der, by  the  union  of  miliary  abscesses,  or  by  pyemia. 

The  symptoms  are  pus  in  the  urine  (this  is  usual,  but 
not  invariable),  hematuria  in  traumatic  cases,  and  pain  run- 
ning into  the  groin.  The  urine  is  usually  alkaline.  Consti- 
tutional symptoms  of  suppuration  exist,  the  fever  being  far 
higher  than  that  usually  met  with  in  renal  tuberculosis. 
The  bladder  should  be  examined  with  a  cystoscope  to  deter- 
mine that  the  turbid  urine  flows  from  a  ureter  and  to  identify 
the  diseased  side.  It  is  well,  if  possible,  to  catheterize  the 
ureters. 

The  treatment  in  the  early  stage  is  rest,  morphin,  purga- 
tion, anodynes,  and  ice-bags  to  the  loin,  followed  in  forty- 
eight  hours  by  hot  fomentations.  When  the  diagnosis  is 
clear  incise  the  loin,  open  and  stitch  the  kidney  to  the  ab- 
dominal wall,  or,  if  the  organ  be  badly  damaged,  remove  it. 

Pyelitis  and  pyelonephritis,  which  usually  affect  only 
one  gland,  are  caused  by  urethral  stricture,  by  stopping  of 
the  ureter  by  blood-clot,  by  vesical  paraly.sis,  by  stone  in  the 
bladder  or  in  the  kidney,  and  by  enlargement  of  the  prostate 
gland. 

Symptoms. — A  patient  who  has,  or  who  has  had,  reten- 
tion of  urine  develops  high  fever,  often  preceded  by  a  chill ; 
headache,  stupor,  and  dry  tongue  are  noted.  Unlike  acute 
Bright's  disease,  there  is  neither  edema  nor  dry  skin,  con- 
vulsions do  not  occur,  and  the  urine  is  plentiful  and  contains 
pus  and,  but  rarely,  blood.     The  prognosis  is  very  bad. 

The  treatment  is  to  remove  the  obstruction  if  possible. 
If  the  urine  be  acid,  give  liquor  potassii  citratis  ;  if  alkaline, 
give  benzoic  acid.  Gallic  acid,  eucalyptol,  and  small  doses 
of  copaiba  or  cubebs  are  recommended.  Venice  turpentine, 
camphor,  and  opium  may  be  given  in  pill-form.  Quinin  is 
used  to  stimulate  the  patient  and  to  lower  fever.  The  bladder 
is  to  be  washed  out  every  day  with  boric-acid  solution  (gr. 
iij-§j).  Cups,  dry  or  moist,  and  hot  sand-bags  or  bran-bags 
are  to  be  applied  to  the  loin.  Alcohol  may  be  sparingly 
administered.     Urotropin  has  lately  been  used  with  benefit. 

Perinephritis  is  an  inflammation  of  the  perinephric  fatty 
tissue  produced  by  cold,  febrile  disease,  slight  traumatism, 
or  spread  of  inflammation  from  another  part. 

The  symptoms  of  this  condition  are  rigidity  of  the  spine, 
the  inclination  being  toward  the  affected  side,  flexion  of  the 
thigh,  and  often  pain  in  the  knee.  The  symptoms  resemble 
those  of  hip-joint  disease  in  the  second  stage.  Suppuration 
may  or  may  not  take  place. 


•JJ^  MODERN  SURGERY. 

The  treatment  is  wet  cups  to  the  loin,  ice-bags  to  the  loin, 
rest,  purgation  by  salines,  morphin  for  pain,  and,  after  the 
acute  stage,  potassium  iodid  internally  and  ichthyol  locally. 

Perinepliric  Abscesses. — An  abscess  in  the  perinephric 
fat  is  known  as  a  perinephric  or  perirenal  abscess.  Primary 
abscess  is  caused  by  chills,  acute  febrile  disturbances,  or  by 
pus  flowing  from  some  other  part,  as  the  spine.  Slight 
traumatisms  by  producing  hemorrhage  make  the  peri- 
nephric region  a  point  of  least  resistance,  and  lead  to 
abscess.  The  causative  injury  may  be  produced  by  dig- 
ging, stamping,  coughing,  falling,  carrying  a  burden,  hfting 
a  weight,  riding  on  a  horse  or  in  a  jolting  wagon.  Consecu- 
tive abscess  is  secondary  to  kidney  inflammation,  suppura- 
tion, calculus,  tuberculosis,  or  cyst.  In  the  consecutive  form 
the  symptoms  may  be  masked  by  the  malady  to  which  peri- 
nephric abscess  is  secondary.  As  a  rule,  in  perinephric 
abscess  there  are  found  the  constitutional  symptoms  of 
suppuration.  The  local  symptoms  are  a  deep  aching  and 
paroxysmal  pain  intensified  by  lumbar  pressure.  Edema  of 
the  corresponding  foot  and  lameness  are  not  unusual.  The 
thigh  is  often  drawn  up.  Edema  of  the  skin  is  usual,  but 
fluctuation  is  rare.  The  exploratory  incision  will  settle  a 
doubtful  diagnosis. 

The  treatment  is  to  lay  open  the  abscess,  wash  it  out, 
and  drain. 

Hydronephrosis  is  a  condition  of  the  kidney  in  which 
an  impediment  to  the  outflow  of  urine  is  caused  by  obstruc- 
tion in  the  ureter,  the  bladder,  or  the  urethra,  the  calyces  of 
the  kidney  becoming  over-distended  with  urine  and  the  gland- 
ular tissue  being  absorbed  by  pressure.  It  has  been  asserted 
by  Albanan  that  secretion  of  urine  ceases  in  a  kidney  whose 
ureter  is  blocked,  distention  being  due  purely  to  congestion. 
This  condition  may  be  congenital,  due  usually  to  twisting 
of  the  ureter  or  to  valve-formation  obstructing  the  ureter 
at  its  point  of  junction  with  the  pelvis  of  the  kidney,  the 
valve  being  produced  because  the  ureter  passes  into  the 
kidney  pelvis  at  an  unnatural  angle.  Occasionally  imper- 
forate meatus  produces  hydronephrosis  of  both  kidneys. 
The  causes  of  the  acquired  form  are  the  pressure  of  pelvic 
growths  or  pregnancy,  inflammation  or  tumor  of  the  blad- 
der, stone  in  the  bladder,  kidney,  or  ureter,  twisting  or  kink- 
ing of  the  ureter  of  a  movable  kidney,  enlargement  of  the 
prostate  gland,  and  stricture  of  the  urethra.  This  acquired 
hydronephrosis  may  involve  both  kidneys,  all  of  one  kid- 
ney, or  only  a  part  of  a  single  gland. 


DISEASES   OF  GENITO-URINARY  ORGANS.  "J-JJ 

Symptoms. — Hydronephrosis  is  most  frequent  in  females. 
When  tumor  is  absent  there  may  be  no  symptoms,  or  there 
may  be  pain  in  the  back  and  abdomen,  frequent  micturition, 
a  persistent  or  intermittent  diminution  in  urine,  or  even  occa- 
sional anuria.  A  tumor  may  be  found  in  the  loin,  which 
growth  is  dull  on  percussion  and  may  come  and  go,  a  large 
urinary  flow  occasionally  occurring  when  it  disappears.  Hy- 
dronephrosis may  last  a  long  while  if  only  one  kidney  be 
invoK-ed,  but  death  is  not  far  distant  if  both  glands  suffer. 
Death  occurs  from  anemia,  from  pressure  on  adjacent  organs, 
or  from  rupture  into  the  peritoneal  cavity.  The  diagnosis  is 
aided  by  the  use  of  the  cystoscope  and  by  catheterizing  the 
ureters. 

Treatment  by  aspiration  may  cure,  but  the  operation  may 
have  to  be  done  repeatedly.  Tapping  on  the  left  side  is 
performed  just  below  the  last  intercostal  space  ;  on  the  right 
side  the  tap  is  made  midway  between  the  last  rib  and  the 
crest  of  the  ilium.  Some  few  cases  have  been  cured  by 
catheterizing  the  ureter  (Pawlik).  The  proper  operation  in 
most  cases  is  nephrotomy,  stitching  the  edges  of  the  cut 
kidney  to  the  surface.  After  the  kidney  has  been  opened 
explore  the  ureter  by  means  of  a  uterine  sound  or  an  elastic 
bougie.  A  healthy  ureter  will  permit  the  passage  of  an 
instrument  of  the  size  of  from  No.  9  to  12  (Fenger).  If  the 
opening  of  the  ureter  into  the  pelvis  cannot  be  found,  open 
the  pelvis  or  open  the  ureter.  A  valve  is  slit  longitudinally 
(Fenger).  If  a  permanent  suppurating  fistula  ensues  or  if 
the  organ  is  found  extensively  damaged,  nephrectomy  is  to 
be  performed,  provided  the  other  kidney  is  in  reasonably 
good  condition. 

Pyonephrosis,  or  surgical  kidney,  is  a  condition  in 
which  the  peh'is  and  the  cahxes  of  the  kidney  are  distended 
with  pus  or  with  pus  and  urine.  The  whole  kidney  may 
be  destroyed.  This  condition  has  the  same  causes  as 
has  hydronephrosis,  for  it  is  in  reality  usually  an  infected 
hydronephrosis.  In  some  cases  the  inaugural  malady 
is  pyelitis,  which  causes  blocking  of  a  ureter.  Watson  of 
Boston  has  reported  two  cases  associated  with  obliteration 
of  the  ureter  by  a  mass  of  fibrous  tissue  (stricture  of  the 
ureter). 

Symptoms. — At  first  the  symptoms  are  those  due  to  the 
obstructing  cause,  plus  pyelitis.  Pus  may  appear  in  the 
urine  in  incomplete  obstruction,  or  it  may  intermittently 
come  and  go.  Constitutional  symptoms  of  suppuration  are 
soon  manifest.     A  tumor  may  appear  in  the  loin,  like  the 


7/8  MODERN  SURGERY. 

tumor  of  hydronephrosis.  If  only  one  kidney  is  involved, 
and  if  the  disease  is  due  to  blocking  of  a  ureter,  recovery 
is  to  be  expected.  The  diagnosis  is  rendered  more  cer- 
tain by  the  use  of  the  cystoscope  and  by  catheterizing  the 
ureters. 

The  treatment  in  the  early  stages  comprises  removal,  if 
possible,  of  the  cause  of  obstruction  and  the  employment  of 
measures  directed  to  the  cure  of  the  pyelitis.  If  obstruction 
is  not  complete,  palliative  measures  may  be  employed  for 
the  tumor.  If  fever  is  continued,  if  there  is  great  visceral 
derangement,  if  pain  is  severe  and  constant,  and  if  the  tumor 
continually  grows,  perform  a  nephrotomy,  stitching  the  organ 
to  the  surface  if  possible,  or  removing  it  if  it  is  hopelessly 
disorganized. 

Chronic  Tuberculosis  of  the  Kidney. — This  condi- 
tion may  begin  in  one  kidney,  no  other  depot  of  infection 
existing  in  the  body.  In  such  cases  the  organisms  were 
deposited  from  the  blood.  The  other  kidney  is  usually 
involved  subsequently,  the  process  in  the  first  kidney  affect- 
ing the  bladder  and  secondarily  the  other  kidney.  The 
important  point  is  that  tuberculosis  of  the  kidney  arising  in 
this  manner  is  at  first  a  unilateral  disease. 

Tuberculosis  of  the  kidney  may  arise  secondarily  to  tuber- 
culosis of  the  prostate  and  bladder.  In  such  a  condition  the 
kidney  disease  is  usually  bilateral. 

SymptorQS. — Renal  tuberculosis  of  arterial  origin  may  ex- 
hibit no  symptoms  until  the  disease  is  far  advanced.  Renal 
tuberculosis  secondary  to  disease  of  the  bladder  or  prostate 
always  presents  symptoms.^  A  very  common  symptom  is 
the  sudden  onset  of  polyuria  and  frequent  micturition.  The 
patient  is  annoyed  day  and  night,  and  in  some  cases  mic- 
turition is  distinctly  painful.  Paroxysms  of  renal  pain  are 
not  unusual.  The  urine  is  acid,  and  may  contain  pus  or 
blood.  Tubercle  bacilli  may  be  found  in  the  urine  or  in 
the  sediment,  but  they  may  be  absent.  Repeated  examina- 
tions should  be  made  before  it  can  be  stated  certainly  that 
bacilli  are  absent.  The  presence  of  bacilli  proves  the  diag- 
nosis, but  their  absence  does  not  negative  it  (Willy  Meyer). 
If  bacilli  are  not  found,  inject  some  of  the  urinary  sediment 
into  a  guinea-pig,  and  note  if  tuberculosis  arises  in  the 
animal.     The  urine  may  or  may  not  be  albuminous. 

Czerny  has  shown  that  in  cases  of  tubercular  kidney  in 
which  bacilli  are  not  found  in  the  urine,  the  administration 
of  tuberculin  will  cause  great  numbers  to  appear.  This  agent 
1  F.  Tilden  Brown,  New  York  Med.  Jour.,  April  lo,  1897. 


DISEASES   OF  GENITOURINARY  ORGANS.  779 

will  also  cause  a  marked  febrile  reaction  if  tuberculosis  exists. 
In  spite  of  the  important  diagnostic  result  of  a  dose  of  tuber- 
culin it  is  scarcely  wise  to  give  it.  as  it  may  cause  dissemi- 
nated tuberculosis. 

In  many  cases  the  kidney  is  obviously  enlarged,  and  this 
area  is  frequently  tender  and  occasionally  painful.  The 
patient  loses  flesh,  and  there  is  nocturnal  fever  followed  by 
sweating.  The  use  of  the  cystoscopc  furnishes  important 
information.  It  shows  from  which  ureter  turbid  urine  is  com- 
ing. Catheterization  of  the  ureters  should  be  practised  by 
some  one  who  is  accustomed  to  employ  it.  Always  examine 
carefully  to  determine  if  one  or  both  kidneys  are  involved, 
if  the  bladder  is  diseased,  and  if  the  prostate  gland  or  semi- 
nal vesicles  are  tubercular. 

Treatment. — Nephrectomy  is  not  justifiable  in  the  very 
beginning  of  a  case,  because  such  a  case  may  attain  to  a 
cure  by  a  combination  of  medical  and  hygienic  treatment, 
and  the  weakening  effect  of  the  operation  of  nephrectomy  may 
cause  the  other  kidney  to  rapidly  develop  tuberculosis.  Tell 
such  a  patient  to  lead  an  outdoor  life.  Brown  recommends 
camp-life  in  the  Adirondacks  during  the  summer,  and  sends 
such  patients  south  during  the  winter.  If  a  patient  cannot  go 
to  another  climate,  urge  upon  him  the  necessity  of  being  much 
out  of  doors.  Insist  upon  the  taking  of  plenty  of  nutritious 
food.     Order  courses  of  creasote  or  guaiacol  carbonate. 

If  the  kidney  is  markedly  enlarged,  if  there  is  profuse 
hematuria,  if  the  fever  is  high  and  persistent,  if  only  one 
kidney  is  involved,  and  if  the  bladder  and  prostate  are  free 
from  disease,  perform  nephrectomy.  In  cases  with  involve- 
ment of  the  other  kidney  or  of  the  genito-urinary  tract  lower 
down,  nephrectomy  is  rarely  justifiable,  although  nephrot- 
omy for  drainage  may  greatly  benefit  the  patient  for  a 
time. 

Operations  on  the  Kidney  and  Ureter. — Nephrot- 
omy means  incision  of  a  kidney,  but  the  term  is  sometimes, 
though  wrongly  applied,  to  the  exploratory  exposure  of  the 
kidney  without  incision.  The  instniincnts  required  are  scal- 
pels, a  blunt-pointed  bistoury,  dissecting-forceps,  toothed  for- 
ceps, a  grooved  director,  hemostatic  forceps,  spatulae,  metal 
retractors,  a  fountain  syringe,  an  Allis  dissector,  Hagedorn 
needles,  and  an  Abbe  needle-holder.  If  looking  for  a  stone, 
have  a  large  harelip-pin  to  sound  with,  forceps  and  a  scoop 
to  remove  the  stone,  and  a  periosteum-elevator  to  scrape 
away  adherent  calculi.  The  patient  lies  upon  the  sound  side, 
a  sand-pillow  being  placed  under  the  loin.     The  incision  is 


780  MODERN  SURGERY. 

made  half  an  inch  below  the  last  rib  and  close  to  the  outer 
border  of  the  erector  spinae  mass,  and  runs  obliquely  down- 
ward and  forward  toward  the  iliac  crest  for  three  inches,  the 
incision  being  enlarged  later  if  required.  Divide  the  skin,  the 
superficial  fascia,  the  fat,  the  external  obhque,  the  posterior 
border  of  the  internal  oblique,  and  the  outer  edge  of  the  latis- 
simus  dorsi.  This  incision  exposes  the  lumbar  fascia.  Push 
aside  the  last  dorsal  nerve  and  incise  the  lumbar  fascia,  when 
the  perirenal  fat  will  bulge  into  the  wound.  Two  distinct 
layers  of  fat  exist.  Tear  this  fat  through  with  dissecting- 
forceps  or  with  an  Allis  dissector  to  expose  the  kidney, 
which  can  now  be  opened  while  it  is  forced  into  the  wound 
by  the  hand  of  an  assistant  making  abdominal  pressure. 

Kocher's  incision  for  nephrotomy  is  begun  in  the  angle 
between  the  sacrolumbalis  muscle  and  the  twelfth  rib,  and  is 
carried  downward,  forward,  and  outward  to  the  axillary  line. 
This  incision  divides  the  skin,  subcutaneous  tissues,  lumbar 
fascia,  the  latissimus  dorsi,  and  the  serratus  posticus  inferior 
muscles. 

Edebohls's  method  enables  the  surgeon  to  most  thor- 
oughly explore  the  kidney,  because  this  organ  is  brought 
outside  of  the  body.  The  patient  lies  prone,  with  a  large 
cylindrical  inflated  rubber  pad  beneath  his  abdomen.  A  ver- 
tical incision  is  made  close  to  the  border  of  the  erector  spinae 
muscle,  from  just  below  the  last  rib  to  just  above  the  iliac 
crest.  The  fatty  capsule  is  well  separated  irova  the  kidney  front 
and  back.  The  patient  is  pulled  by  the  legs  toward  the  foot 
of  the  table,  the  pad  remaining  stationary.  This  change  of 
position  brings  the  pad  beneath  the  chest,  abdominal  respi- 
ration takes  place,  the  kidney  is  forced  out  of  the  wound, 
and  can  be  thoroughly  examined. 

Nephrolithotomy. — In  this  operation  the  incision  is  the 
same  as  in  nephrotomy.  If  the  kidney  is  not  much  enlarged, 
it  can  be  brought  out  by  Edebohls's  method.  Feel  the  kid- 
ney for  a  stone,  or,  if  this  procedure  fails,  explore  with  a  needle 
or  a  pin.  If  no  stone  is  found,  open  the  pelvis,  let  an  assist- 
ant grasp  the  pedicle  with  his  fingers  or  with  a  pair  of  forceps, 
each  blade  of  which  is  covered  with  a  bit  of  rubber  tube,  while 
the  surgeon  opens  into  and  explores  with  the  finger.  If  a 
stone  is  detected,  open  the  kidney-tissue,  loosen  the  calculus 
with  the  nail,  and  remove  it  with  the  finger,  with  a  scoop,  or 
with  forceps.  After  removing  the  stone  suture  the  incision 
with  catgut,  and  release  the  pressure  on  the  pedicle.  Hem- 
orrhage will  rarely  occur.  If  in  spite  of  this  plan  bleeding 
occurs,  take   out  the  stitches  and  apply  pressure  and  hot 


DISEASES   OF  GENITO-URIXARY  ORGANS.  78 1 

water,  or  in  some  cases  plug  with  iodoform  gauze  for  twenty- 
four  hours.  When  hemorrhage  ceases  put  a  large  drainage- 
tube  down  to  the  kidney.  Close  the  wound  in  the  muscles 
and  integument  and  dress  antiseptically.  The  dressings  must 
be  changed  frequently  and  the  tube  should  be  shortened 
dail}'. 

Nephrectomy  is  the  removal  of  a  kidney.  There  are  two 
methods  of  nephrectomy,  the  lumbar  and  the  abdominal.  Be- 
fore performing  nephrectomy  ascertain  the  competence  of  the 
kidneys.  If  at  least  i  per  cent,  of  urea  is  not  being  excreted, 
it  is  very  unsafe  to  operate.  Be  sure  the  patient  possesses  two 
kidneys.  Examination  of  the  bladder  by  a  cystoscope  will 
show  the  ureteral  orifices,  a  strong  indication  that  both  kid- 
neys are  present.  Nevertheless,  when  we  reflect  that  a 
horseshoe  kidney  has  two  ureters  the  proof  is  not  absolute. 
Catheterization  of  the  ureters  is  advisable  if  it  can  be  per- 
formed, but  it  will  probably  require  a  specialist  to  perform 
it.  Proof  absolute  of  the  presence  of  two  kidneys  consists 
in  feeling  both  of  them.  If  in  doubt  as  to  the  question,  and 
if  uncertain  as  to  the  competence  of  the  organ  which  is  to 
be  left,  feel  each  kidney  during  the  operation  and  before 
removing  either,  or  perform  a  preliminary  exploratory 
laparotomy. 

Lumbar  Nephrectomy. — The  instruments  required  for 
this  operation  are  scalpels,  a  blunt-pointed  bistour}%  forceps 
as  used  in  the  preceding  operation,  a  clamp,  retractors, 
spatulae,  blunt  hooks,  an  aneurysm-needle,  a  pedicle-needle, 
a  grooved  director,  stout  silk,  an  Allis  dissector,  sharp 
spoons,  and  a  Paquelin  cauter^^  The  patient  is  placed  on 
the  sound  side  and  a  pillow  is  placed  under  the  loin.  Sev- 
eral incisions  have  been  proposed.  In  many  cases  the 
oblique  incision  is  first  made  to  permit  of  exploration.  This 
incision  is  begun  half  an  inch  below  the  last  rib  and  by  the 
edge  of  the  erector  spinae  muscle,  and  is  carried  downward 
and  forward  toward  the  iliac  crest.  In  some  cases  a  kidney 
can  be  removed  through  this  cut.  In  other  cases  the  cut 
must  be  enlarged.  It  can  be  enlarged  by  extending  the  cut 
downward.  Morris  enlarges  it  by  adding  to  it  a  vertical 
incision,  which  begins  one  inch  below  the  origin  of  the 
oblique  cut.  Konig's  incision  for  nephrectomy  consists  of 
a  vertical  cut  by  the  edge  of  the  erector  spinae,  carried  almost 
to  the  iliac  crest,  from  which  point  it  is  curved  forward 
toward  the  umbilicus,  and  is  carried  to  or  even  through 
the  rectus  muscle.  After  thorough  exposure  lift  the  kidney, 
and  separate  it  from  the  peritoneum,  if  possible,  with  the 


782  MODERN  SURGERY. 

finger;  clamp  the  pedicle;  pass  an  armed  aneurysm-needle 
between  the  vessels  of  the  pedicle;  ligate  in  two  places;  cut 
between  the  threads ;  and  arrest  hemorrhage  by  ligature  or 
by  the  cautery.  If  the  ureter  be  healthy,  ligate  it  with  silk 
and  drop  it  back ;  if  it  be  foul  and  purulent,  scrape  it  with 
a  spoon,  wash  it  with  corrosive  sublimate,  and  touch  it  with 
pure  carbolic  acid,  and  then  either  ligate  it  and  drop  it  back 
or  sew  it  into  the  wound.  If  hemorrhage  persists  from  the 
wound,  plug  with  gauze.  Put  in  a  drainage-tube  and  close 
the  wound.  If  the  peritoneum  be  accidentally  opened,  close 
it  with  Lembert's  suture.  Kocher's  method  is  excellent, 
and  enables  the  surgeon  to  feel  the  opposite  kidney  before 
removing  the  one  which  is  known  to  be  diseased.  The 
incision  is  begun  as  described  on  page  781,  and  is  car- 
ried forward  so  as  to  expose  the  reflection  of  the  perito- 
neum onto  the  colon  in  the  posterior  axillary  line.^  At  this 
point  the  peritoneum  is  opened,  and  the  hand  is  inserted 
into  the  abdominal  cavity  and  feels  the  other  kidney.  If 
another  kidney  exists  and  it  is  found  to  be  healthy,  the 
diseased  organ  is  removed. 

Abdominal  nephrectomy  is  more  dangerous  than  the 
lumbar  operation.  The  same  instruments  are  required  as 
are  used  in  the  preceding  operation.  The  position  is  supine. 
The  incision  is  that  of  Langenbeck — four  inches  long  in  the 
linea  semilunaris,  its  center  corresponding  to  the  umbilicus. 
Open  the  abdomen,  introduce  a  hand,  feel  the  kidneys,  and 
if  both  show  serious  disease  do  not  perform  nephrectomy. 
Keep  the  small  intestine  away  by  sponges,  push  the  colon 
toward  the  umbilicus,  incise  the  outer  layer  of  the  meso- 
colon, and  bare  the  kidney.  Strip  off  the  peritoneum  from 
the  kidney  and  its  vessels,  and  ligate  the  vessels  by  pass- 
ing strong  silk  through  the  center  of  the  pedicle  with  an 
aneurysm-needle.  Ligate  the  ureter  if  healthy,  and  cut.  If 
the  ureter  is  septic,  fasten  it  to  an  opening  made  in  the  loin 
by  cutting  onto  forceps  pushed  to  the  outer  edge  of  the 
quadratus  lumborum.  Stop  bleeding,  irrigate  the  belly- 
cavity,  and  dress  as  usual,  employing  drainage  only  when 
septic  matter  has  gotten  into  the  peritoneal  cavity  or  when 
oozing  is  persistent. 

Partial  Nephrectomy.— This  operation  may  be  performed 
in  some  cases  for  wounds,  cysts,  and  innocent  tumors.  After 
removing  the  damaged  or  diseased  part  bleeding  points  are 
ligated  with  catgut.  The  wound-surfaces  are  approximated 
as  well   as   pcfssible  by  catgut  sutures.     Drainage  is  intro- 

^  Kocher's  Text-book  of  Operative  Surgery. 


DISEASES   OF  GENITOURINARY  ORGANS.  783 

duced.  The  value  01  partial  nephrectomy  in  some  cases 
seems  certain,  and  we  should  apply  it  when  possible  instead 
of  the  complete  operation.' 

Renipuncture. — This  is  an  operation  devised  by  Reginald 
Harrison  for  the  relief  of  albuminuria  due  to  elevated  ten- 
sion. The  kidney  is  exposed  in  the  loin  and  the  capsule  is 
punctured  or  incised.  Simple  incision  of  the  capsule  will 
usually  relieve  nephralgia. 

Nephrorrhaphy  (or  Nephropexy)  is  fixation  of  a  mobile 
kidney.  The  kidney  is  exposed  in  the  loin  as  above  detailed, 
and  is  forced  out  of  the  wound  by  Edebohls's  method.  The 
fibrous  capsule  is  incised  longitudinally  and  a  cuff  is  turned 
down  on  each  side.  Sutures  traverse  the  kidney-substance 
and  two  layers  of  capsule  on  each  side.  The  upper  suture 
catches  the  periosteum  of  the  last  rib,  the  lower  sutures 
catch  the  lumbar  fascia.  Drainage  is  not  required.  The 
suture-material  is  kangaroo-tendon  or  chromicized  catgut. 
Kocher's  incision  is  shown  in  Fig.  64.  Many  surgeons 
simply  pass  sutures  through  the  uncut  capsule  and  kidney- 
substance,  and  fasten  the  kidney  to  the  lumbar  fascia.  Other 
surgeons  split  the  capsule,  pull  it  into  the  wound,  and  pass 
sutures  through  only  the  capsule  and  wound-edges.  After 
nephrorrhaphy  keep  the  patient  in  bed  for  three  weeks.  A 
kidney  which  has  been  anchored  wjll  not  unusually  loosen 
at  some  future  time. 

Ureterolithotomy. — If  the  stone  is  impacted  in  the  upper 
two-thirds  of  the  tube,  make  the  incision  advised  for  wounds 
of  the  ureter  (p.  772).  The  operation  is  extraperitoneal.  The 
tube  is  opened  by  a  longitudinal  incision.  The  stone  is  re- 
moved. The  ureter  is  explored  by  means  of  a  sound.  It  is 
not  necessar>'  to  suture  the  ureter.  The  tissues  above  the 
ureter  are  sutured  and  a  drainage-tube  is  carried  to  the  ureter 
(Fenger).  If  the  stone  cannot  be  reached  by  the  extra- 
peritoneal method,  open  the  peritoneal  cavit)'  and  incise  the 
ureter.  After  removing  the  stone  suture  the  wound  in  the 
ureter  with  silk  inversion-sutures,  fasten  an  omental  graft 
over  the  suture-line  (Fenger),  and  drain. 

Uretero-ureterostomy  (Van  Hook's  Operation). — In  this 
operation  ligate  the  lower  end  of  the  divided  ureter  with 
silk  or  catgut.  About  one-fourth  of  an  inch  below  the  liga- 
ture make  an  incision  in  the  long  axis  of  the  tube.  This 
incision  is  in  length  equal  to  twice  the  diameter  of  the  tube. 
Each   end   of  a  piece   of   fine  catgut   is   threaded  to  a   fine 

'  See  Oscar  Bloch  in  British  Med.  Jour.,  Oct.  17,  1S96;  also,  reports  of 
Czemy,  Bardenheuer,  Tuffier,  Kiimmell. 


784 


MODERN  SURGERY. 


needle.  This  thread  is  passed  through  the  upper  end  of 
the  ureter  (Fig.  286).  The  needles  are  made  to  enter  the 
lower  end  of  the  tube  through  the  door  made  by  the  sur- 


FlG.   2 


Van  Hook's  method  of  ureteral  anastomosis. 


geon.  They  are  pushed  through  the  wall  of  the  ureter  one- 
half  an  inch  below  the  window  (Fig.  286).  Traction  upon 
the  strings  causes  invagination  and  the  ligature-ends  are  tied. 
If  the  operation  is  intraperitoneal,  the  ureter  is  wrapped 
about  with  peritoneum. 


Diseases  and  Injuries  of  the  Bladder. 

Retention  of  Urine. — By  this  term  is  meant  an  inability 
to  empty  the  bladder.  The  retention  may  be  complete,  not 
a  drop  emerging,  or  it  may  have  been  complete,  a  dribbling 
setting  in  after  a  time,  due  to  paralysis  of  the  bladder,  which 
cannot  contain  more  fluid,  expulsion  of  the  overflow  from  the 
ureters  being  produced  by  atmospheric  pressure.  This  con- 
dition is  known  as  the  engoi^gement,  the  overflow,  or  the  in- 
continence of  retention.  There  may  be  a  partial  retention 
from  enlarged  prostate,  a  portion  only  of  the  urine  being 
voided.  Retention  may  be  caused  by — (i)  obstruction,  result- 
ing from  urethral  stricture,  hypertrophied  prostate,  inflamed 
prostate,  occluded  meatus,  impacted  calculus,  urethral  tumors, 
complete  phimosis,  fecal  impaction,  and  pressure  from  large 
tumors,  or  by  (2)  defective  expulsion,  resulting  froin  paralysis, 


DISEASES   OF  GENITO-URINARY  ORGANS.  785 

disease  or  injury,  atony,  reflex  inhibition,  shock,  muscular 
weakness  of  fevers,  and  the  action  of  such  drugs  as  bella- 
donna, opium,  or  cantharides. 

Symptoms. — In  acute  retention  there  is  an  agony  of  desire 
to  urinate,  the  patient  making  acutely  painful  straining-efforts, 
during  which  feces  are  often  passed.  There  are  severe  pain 
and  aching  in  the  abdomen,  thighs,  perineum,  and  penis. 
All  the  symptoms  rapidly  increase,  a  typhoid  state  is  inau- 
gurated, and  death  closes  the  scene  unless  relief  be  given. 
If  retention  is  from  time  to  time  alleviated  by  the  passage 
of  a  little  water,  the  symptoms  are  slower  in  evolution  and 
are  less  intense,  and  the  case  is  said  to  be  chronic.  Some 
cases  of  gradual  onset,  due  to  atony,  are  very  insidious,  the 
patient  feeling  no  particular  pain  and  complaining  only  of 
the  dribbling,  which  is  really  the  overflow  of  retention,  and 
is  not  a  sign  that  the  bladder  is  successfully  emptying  itself. 
In  any  case  of  retention  the  bladder  rises  above  the  pubes, 
and  there  is  found  a  pyriform,  elastic,  fluctuating  tumor  (dull 
on  percussion)  in  the  hypogastrium,  which  tumor  gradually 
enlarges  until  the  bladder  is  evacuated  or  incontinence  sets 
in.    The  flanks  give  a  clear  percussion-note,  and  the  tumor  is. 


Fig.  287— Gouley's  tunnelled  catheter,  threaded  over  a  filiform  bougie. 

more  prominent  when  the  patient  is  erect  than  when  recum- 
bent. Long  continuation  of  obstructive  disease,  producing 
partial  retention  with  or  without  attacks  of  complete  reten- 
tion, disorganizes  the  kidneys.  Acute  and  complete  retention 
may  induce  rupture  of  the  urethra  or  urinary  suppression. 

Treatment. — Place  the  patient  upon  his  back,  keep  him 
warm,  and  if  instrumentation  does  not  rapidly  succeed,  give 
an  anesthetic.  Be  sure  that  every  instrument  is  aseptic. 
In  organic  stricture  try  to  pass  a  soft  catheter;  if  this 
fails,  endeavor  to  insert  a  hard  catheter.  Try  a  large  size 
first,  and  gradually  go  to  smaller  sizes  if  the  larger  instru- 
ment will  not  pass  the  obstruction.  When  the  instrument 
enters  the  bladder  draw  off  but  half  of  the  urine,  withdraw 
the  instrument,  wait  a  few  hours,  insert  it  again  and  then 
empty  the  bladder  and  wash   out  the  viscus  with  hot  boric- 

50 


785  MODERN  SURGERY. 

acid  solution.  To  draw  off  all  of  the  urine  at  once  is  dan- 
gerous, because  the  sudden  relief  of  pressure  from  distended 
veins  leads  to  bleeding  from  the  mucous  membrane  and 
hemorrhage  into  the  bladder-walls.  Fig.  289  shows  several 
varieties  of  rubber  catheters,  and  Fig.  291  shows  a  silk 
catheter.  Fig.  290  shows  the  proper  curve  and  the  im- 
proper curve  for  a  metal  instrument.  After  the  bladder  has 
been  emptied  the  patient  is  wrapped  in  blankets,  a  bag  of 
hot  sand  is  placed  against  the  perineum,  and  a  hot-water  bag 
over  the  hypogastric  region ;  when  he  recovers  from  the 
effect  of  the  anesthetic  he  is  given  suppositories  of  opium 
and  belladonna,  and  tablets  of  salol  and  boric  acid  are 
administered  for  several  days.  If  it  is  found  impossible  to 
insert  a  rubber  instrument  or  a  metal  catheter,  make  an 
attempt  to  carry  a  filiform  bougie  into  the  bladder.  Fig.  288 
shows  filiform  bougies.  If  the  stricture  is  known  to  be 
organic  from  previous  histor}^,  at  once  insert  a  filiform 
bougie.  On  this  bougie  Gouley's  tunnelled  catheter  can  be 
threaded  (Fig.  287)  and  carried  into  the  bladder,  the  viscus 
being  half  emptied.  Instead  of  carrying  in  the 
/        <;  I      catheter,  we  can  leave  the  filiform  in  place, 

and  fasten  it.  The  filiform  bougie  will  act 
as  a  capillary  drain,  and  in  a  few  hours 
will  empty  the  bladder.  Then  insert  an- 
other bougie  beside  the  first,  and  so  on 
for  several  days,  using  also  opium,  order- 
FiG.  288.— Points  ing  rest  in  bed,  and  making  no  attempt  to 
w  gu'rdes.  ^^^^^'  dilate  the  stricture  forcibly  until  retention 
has  ceased  and  inflammation  has  subsided. 
If  no  bougie  can  be  passed,  aspirate  or  perform  cystotomy  (su- 
prapubic or  perineal).  In  spasmodic  stricture  hold  a  good-sized 
metal  catheter  firmly  against  the  face  of  the  spasmed  area : 
relaxation  will  occur  and  the  instrument  will  eventually  pass. 
An  individual  who  has  an  organic  stricture  which  has  given 
but  little  trouble  may  develop  attacks  of  retention  because 
of  inflammatory  edema  of  the  mucous  membrane  and  spasm 
of  the  urethral  muscles.  These  attacks  are  temporary,  and  an 
instrument  can  usually  be  inserted  when  employed  as  above 
•directed.  In  inflmnviations  give  a  hot  hip-bath  and  sup- 
positories of  opium  and  belladonna,  and  then  use  a  hot 
sand-bag  to  the  perineum  and  a  hot-water  bag  over  the 
hypogastrium.  If  these  fail  or  if  the  symptoms  are  urgent, 
pass  a  soft  catheter.  In  the  occluded  meatus  of  the  nezv- 
borri  incise  with  a  tenotome.  In  a  congenital  cyst  of  the 
sinus  pocularis   pass    a    steel    bougie,    which    will    rupture 


DISEASES   OF  GENITO-URINARY  ORGANS. 


787 


the  cyst.  In  complete  phimosis  split  up  the  prepuce.  In 
impacted  stone  try  to  pull  it  out  with  urethral  forceps ;  if 
this  fails,  push  it  in  or  cut.  In  fecal  impaction  scrape  out 
with  a  spoon.  In  enlarged  prostate  insert  a  coude  cath- 
eter (Fig.  289,  U)  strengthened  by  the  insertion  of  a  filiform 


Fig 


I. — a,  French   olivary   gum   catheter;    /',  Mercier's   elbowed   catheter  (coude); 
c,  Mercier's  double-elbowed  catheter  ;  d,  curved  gum  catheter. 


bougie  nearly  to  the  beak  (Brinton),  or  pass  a  silver  instru- 
ment with  a  large  curve.  In  retoition  from  expidsive  defect 
use  a  soft  catheter.  Cases  of  retention  require  warmth,  con- 
finement to  bed,  the  administration  of  laxatives,  free  action 
of  the  skin,  and  the  use  of  such  drugs  as  salol,  boric  acid, 
and  quinin  to  asepticize  the  urine.  In  some  few  cases  no 
instrument  can  be  inserted  in  the  bladder.  In  most  of  such 
cases  aspirate — which  may  be  done  several  times  if  necessary 
— and  in  a  day  or  two,  when  swelling  and  congestion  abate, 
an  instrument  can  be  passed.  A  small  trocar  or  an  aspirator- 
needle  is  pushed  into  the  bladder,  the  trocar  or  needle  being 
inserted  in  the  median  line,  just  above  the  pubes,  and  taking 
a  course  downward  and  backward.  The  parts  are  first  pre- 
pared antiseptically,  and  the  puncture  is  dressed  with  iodo- 
form and  collodion.  Only  half  of  the  urine  is  withdrawn 
at  a  first  aspiration.  Rectal  puncture  is  now  obsolete.  The 
perineal  incision  is  not  advocated  for  retention  unless  rupture 
of  the  urethra  has  taken  place.  When  a  catheter  is  used  for 
retention  the  patient  must  be  recumbent  to  minimize  shock. 

Injuries  of  the  Bladder. — This  viscus  is  so  deeply  situ- 
ated, and  the  abdominal  walls  are  so  elastic,  that  it  is  rarely 
injured  when  empty.  If  the  bladder  be  full  and  the  abdomen 
be  tense — which  is  common  in  alcoholic  intoxication — force 
applied  upon  the  abdomen  may  injure  the  bladder. 

Contusion  of  the  Bladder. — In  this  condition  there  are 
noted,  vesical  hematuria,  tenesmus,  severe  cystitis,  and  an 
impediment  to  the  flow  of  water  because  of  clots.     Hemor- 


788 


MODERN  SURGERY. 


rhage  may  be  very  severe  and  sepsis  may  arise,  even  causing 
death.  When  contusion  exists  retention  is  relieved  by  a 
clean  soft  catheter;  if  this  fails  because  of  occlusion  of  the 
eye  of  the  catheter  with  blood-clot,  there  must,  from  time 
to  time,  be  forced  through  the  catheter  by  an  irrigator  a  solu- 
tion of  sodium  bicarbonate  in  cooled  boiled  water.  Gross's 
blood-catheter  can  be  used,  or  the  evacuator  of  Bigelow 
may  be  employed.  The  patient  is  put  to  bed,  a  hot-water 
bag  is  apphed  to  the  hypogastrium,  morphin  is  administered 
in  moderate  doses,  the  bladder  is  washed  out  several  times 


Fig.  290. — A  B  E  shows  the  proper  curve  (reduced  in  size)  for  unyielding  male  urethral 
instruments  ;    C  B  D  shows  an  improper  curve. 

a  day  with  boric-acid  solution  to  disintegrate  and  remove 
blood-clots,  and  the  urine  is  diluted  and  rendered  aseptic  by 
the  stomach  administration  of  salol,  boric  acid,  and  hquor 
potassii  citratis.  Hemorrhage  usually  ceases  on  relieving 
distention ;  if  it  does  not,  some  more  radical  measure  must 
be  employed  (see  Hematuria). 

Besides  contusions,  the  bladder  maybe  injured  by  bullets; 
by  stabs  or  punctures  through  the  abdomen,  the  vagina,  or 
the  uterus ;  or  by  penetration  by  a  fragment  of  a  fractured 
pelvic  bone.  The  symptoms  of  such  conditions  are  those 
of  rupture  of  the  bladder  (^.  •z/.).  In  any  intraperitoneal 
wound  at  once  open  the  abdomen,  suture  the  wound  in  the 
bladder-wall,  irrigate  the  peritoneal  cavity,  and  drain  the 
bladder  by  means  of  a  retained  catheter,  a  perineal  section, 
or  a  suprapubic  cystotomy.  In  an  extraperitoneal  wound 
drain  the  wound  by  a  tube,  and  drain  the  bladder  by  a  re- 
tained catheter,  a  perineal  section,  or  a  suprapubic  opening. 

Rupture  of  the  bladder  occurs  in  three  forms  :  (i)  intra- 
peritoneal— a  rupture  involving  the  peritoneal  coat ;  (2)  ex- 
traperitoneal— a  rupture  of  a  portion  of  the  bladder  not 
covered  by  peritoneum  ;  and  (3)  subperitoneal — a  rupture  of 
the  mucous  and  muscular  coats,  the  urine  diffusing  under 


DISEASES   OF  GENITO-UFINARY  ORGANS.  789 

the  peritoneal  investment.  The  catiscs  are  of  two  kinds, 
predisposing  and  exciting.  Predisposing  causes  are — disten- 
tion of  bladder ;  drunkenness  ;  ulceration ;  degeneration  or 
atony  of  the  bladder-coats.  Exciting  causes  are — obstruc- 
tion to  outflow  of  urine  (by  stricture  or  enlarged  prostate) ; 
external  violence ;  falls  upon  the  feet  and  the  buttocks,  as 
well  as  upon  the  abdomen ;  lifting ;  straining  at  stool,  in 
micturition,  or  during  parturition ;  and  the  forcing  of  injec- 


FiG.  291. — English  silk-web  catheter. 

tions  into  the  bladder.  This  accident  is  commoner  in  men 
than  in  women  (10  to  i),  and  is  rare  in  children. 

Syjuptovis,  Diagnosis,  and  Treatment. — The  symptoms  are 
not  always  definite,  and  every  characteristic  one  may  be  for 
a  time  absent,  the  patient  seeming  in  some  rare  instances  to 
possess  the  power  of  retaining  his  urine  and  of  voiding  it. 
As  a  rule,  however,  there  are  found  some  or  all  of  the  follow- 
ing symptoms,  following  an  accident  or  occurring  during  the 
progress  of  a  causative  disease :  collapse ;  excessive  desire 
to  urinate ;  inability  to  do  so  ;  a  catheter,  when  used,  brings 
away  pure  blood  or  a  veiy  little  bloody  urine ;  the  catheter 
occasionally  slips  through  the  tear  into  a  cavity,  and  more 
bloody  water  comes  away ;  severe  hypogastric  pain  comes 
on  after  a  temporary  sense  of  relief  from  retention  ;  shock 
is  so  severe  that  death  may  ensue ;  if  reaction  follows,  there 
is  delirium,  often  septicemia  and  peritonitis  ;  extensive  infil- 
trations of  urine  may  occur.  In  intrapeintoneal  rupture  gen- 
eral peritonitis  is  certain  to  arise,  but  its  appearance  may 
be  postponed  for  several  days  if  the  urine  is  healthy.  In 
these  cases  the  extravasation  is  noted  as  a  simple  swelling, 
probably  on  one  side  only.  In  extraperitoneal  rnptnre  the 
urine  may  infiltrate  the  perineum,  the  scrotum,  the  thighs, 
and  under  the  integuments  of  the  abdomen  and  the  back, 
and  may  soon  induce  sloughing.  In  subperitoneal  rnptnre 
peritonitis  is  apt  to  arise.  Injecting  fluid  fails  to  lift  the 
bladder  into  the  hypogastric  region  so  as  to  be  recognizable 
on  percussion.  If  there  is  injected  a  measured  amount  of 
fluid,  less  will  run  out  than  went  in. 

In  doubtful  cases  pump  air  into  the  bladder.  A  bicycle 
pump  can  be  used  (Brown),  or  a  Davidson  syringe  (Keen). 
Keen's  directions  are  to  insert  a  catheter,  empty  the  blad- 
der  of    urine,    and   connect   to  the   catheter   a   disinfected 


790  MODERN  SURGERY. 

Davidson's  syringe,  a  mass  of  absorbent  cotton  being  fast- 
ened over  the  distal  end  of  the  syringe.  Air  after  it  has 
filtered  through  the  cotton  is  pumped  into  the  bladder :  an 
unruptured  bladder  will  rise  above  the  pubes  as  a  pyriform 
tumor,  tympanitic  on  percussion  ;  a  ruptured  bladder  will  not 
so  rise,  but  the  air  will  pass  into  the  general  peritoneal  cavity. 
In  intraperitoneal  rupture  the  general  peritoneal  cavity  will  be 
distended  with  the  air.  In  extraperitoneal  rupture  injection 
will  produce  emphysema  of  the  extravesical  connective  tissues. 
On  removing  the  syringe  the  air  rushes  out  again  if  the 
bladder  is  unruptured,  but  little  if  any  comes  aw^ay  if  it  is 
ruptured.  Senn  recommends  injecting  hydrogen  gas  instead 
of  air.  The  treatment  of  rupture  of  the  bladder  is  the  same 
as  that  for  wounds  of  the  bladder. 

Atony  of  the  bladder  is  a  condition  in  which  the  expul- 
sive power  of  the  bladder  is  diminished  or  lost  because  of 
impairment  of  muscular  tone.  The  bladder  is  very  thin, 
and  the  muscles  are  flaccid  and  often  the  seat  of  fatty  degen- 
eration. Sometimes  the  bladder  is  very  large  and  sometimes 
it  is  very  small.  A  slight  degree  of  atony  is  physiological 
after  middle  age.  The  causes  are  senility,  distention  from 
true  paralysis,  chronic  over-distention  from  obstruction,  and 
acute  over-distention. 

Symptoms. — In  atony  of  the  bladder  the  patient  passes 
water  frequently  (a  symptom  probably  existing  for  some 
years),  and  especially  at  night ;  he  may  even  do  so  while 
asleep.  The  stream,  when  voluntarily  passed,  has  no  pro- 
jection, but  drops  at  once  from  the  end  of  the  penis.  Resid- 
ual urine  exists  for  years  and  may  at  any  time  set  up  cystitis, 
and  retention  with  incontinence  is  apt  to  occur.  This  con- 
dition is  not  vesical  paralysis  resulting  from  a  lesion  of  the 
nervous  system. 

Treatment. — In  treating  atony  of  the  bladder  measure 
the  residual  urine  :  if  it  amounts  to  four  ounces,  use  a  soft 
catheter  night  and  morning  ;  if  it  amounts  to  six  ounces, 
use  the  catheter  every  eight  hours  ;  if  it  amounts  to  eight 
ounces,  use  the  catheter  every  six  hours  (J.  W.  White). 
The  patient  should  be  taught  how  to  use  the  catheter  and 
how  to  keep  it  sterile.  (For  methods  of  disinfecting  cath- 
eters see  article  on  Hypertroph}^  of  the  Prostate  Gland.) 
The  bladder  is  from  time  to  time  washed  out  with  gr.  iij  to 
the  ounce  of  boric-acid  solution  at  a  temperature  of  iOO°  F. 
Strychnin,  electricity,  ergot,  and  cantharides  may  be  ordered. 

Vesical  Calculus,  or  Stone  in  the  Bladder. — The 
salts  normally  in  solution  in  the  urine  may  deposit  as  calculi 


DISEASES   OF  GENITO-URINARY  ORGANS.  79 1 

and  may  be  imprisoned  in  any  portion  of  the  urinary  tract. 
The  commonest  calcuh  are  those  composed  of  uric  acid, 
urates,  calcium  oxalate,  and  fusible  phosphates.  The  for- 
mation of  uric-acid  and  urate  calculi  is  explained  under 
Renal  Calculus  (page  772).  Vesical  calculi  are  usually 
renal  calculi  that  have  passed  the  ureter  and  become 
enlarged  by  new  accretions.  Phosphatic  calculi  may  be 
formed  in  the  bladder  when  chronic  cystitis  causes  and 
maintains  an  alkaline  urine.  Uric-acid  calculi  are  smooth, 
round  or  oval,  and  hard,  but  easily  broken.  On  section 
they  present  the  color  of  brick-dust  and  are  marked  by 
concentric  rings.  Their  nuclei  are  dark  by  comparison. 
They  are  soluble  in  dilute  potassium  hydrate,  and  with 
effervescence  in  nitric  acid.  They  are  combustible,  and 
leave  scarcely  any  ash.  Urate  of  sodium  and  urate  of 
ammonium  often  occur  together  in  stones,  and  these  calculi 
are  not  in  rings,  are  not  so  hard  as  the  uric-acid  stones, 
and  are  fawn-colored  on  section.  Oxalate-of-lime  stones 
are  round  with  many  projecting  nodes  like  the  mulberry, 
hence  the  term  "  mulberry  calculus."  They  are  very  hard, 
and  section  shows  the  color  to  be  brown  or  green  and  that 
they  possess  wavy,  concentric  rings.  This  form  of  calculus 
is  soluble  in  hydrochloric  acid.  Fusible  calculus,  which  is 
composed  of  magnesic  ammonic  phosphate  with  phosphate 
of  lime,  constitutes  the  commonest  form  of  phosphatic 
stones  and  of  large  stones.  It  is  light,  soft,  smooth,  and 
white,  and  shows  no  laminae  on  section.  Some  rare  forms 
of  stone  are  composed  of  xanthic  oxid,  cystic  oxid,  calcium 
phosphate  or  carbonate,  and  magnesic  ammonic  phosphate 
(triple  phosphate). 

A  stone  may  be  formed  having  layers  of  different  sub- 
stances ;  for  instance,  there  is  often  found  a  uric-acid  nucleus 
surrounded  by  phosphates,  the  latter  surrounded  by  uric 
acid  or  urates,  and  these  again  by  phosphates.  In  some 
cases  oxalate  of  lime  alternates  with  uric  acid,  urates,  or 
phosphates  (Bowlb)^).  Bowlby  states  that  the  alternating 
uric-acid  and  phosphatic  layers  are  due  to  the  altering  reac- 
tions of  the  urine;  that  when  the  urine  is  acid  uric  acid 
is  deposited  on  the  stone,  but  when  cystitis  makes  the  urine 
alkaline  the  stone  receiv^es  a  phosphatic  coat. 

Anything  that  favors  the  formation  of  an  excessive  uri- 
nary deposit  may  cause  vesical  calculus,  and  among  such 
causes  are  defective  digestion,  failure  in  processes  of  oxida- 
tion, excess  of  solids  and  nitrogenous  elements  in  the  diet, 
deficient  exercise,  etc.       If  to  the  urinary  condition  estab- 


792  MODERN  SURGERY. 

lished  by  the  above  conditions  a  catarrh  of  the  genito-uri- 
nary  tract  is  added,  pus  or  mucopus  in  the  concentrated  urine 
may  induce  stone.  Children  are  predisposed  to  uric-acid 
stones,  and  old  people  to  phosphatic  stones.  In  an  old 
man  with  enlarged  prostate  and  chronic  cystitis  a  stone 
forms  rapidly  about  any  accidental  nucleus.  The  nucleus 
may  be  phosphate-crystals  glued  together  by  mucus,  a 
blood-clot,  uric-acid  gravel,  or  a  foreign  body.  Stone  is 
rare  in  females  because  of  the  shortness,  the  large  diam- 
eter, and  the  ready  dilatability  of  the  urethra.  Stone  is  very 
rare  in  the  negro.  Gout,  rheumatism,  lithemia,  enlarged 
prostate,  vesical  atony,  urethral  stricture,  and  catarrhal  in- 
flammation of  the  kidney,  the  ureter,  and  the  bladder,  are 
predisposing  causes. 

Symptoms. — In  not  a  few  cases  the  vesical  symptoms  are 
antedated  by  an  attack  of  nephritic  colic.  The  severity  of 
the  symptoms  depends  more  on  the  roughness  of  the  stone 
than  on  its  size.  A  small,  rough  calculus  will  produce  intoler- 
able anguish,  whereas  several  large,  smooth  stones  will  cause 
but  moderate  pain,  A  patient  with  stone  in  the  bladder 
complains  of  frequency  of  micturition,  particularly  in  the 
daytime,  the  desire  being  sudden,  uncontrollable,  and  in- 
voked or  aggravated  by  exercise.  This  symptom  is  more 
positive  in  youth  than  in  old  age.  Pain  of  a  sharp,  burning 
character  is  experienced  at  the  end  of  micturition,  due  to 
the  contraction  of  the  empty  bladder  upon  the  stone.  The 
usual  seat  of  this  pain  is  the  under  surface  of  the  head  of 
the  penis,  a  little  behind  the  meatus,  and  the  pain  may  con- 
tinue for  some  time.  By  pulling  on  the  penis  to  relieve  this 
pain  the  prepuce  often  becomes  pendulous.  This  pain  varies 
in  severity,  being  worse  during  cystitis  and  after  exercise ;  it 
may  be  absent  in  encysted  stone,  it  may  even  almost  disap- 
pear, and  it  is  always  worse  in  the  young  than  in  the  old. 
Stone  in  chronic  cases  of  atony  and  in  cases  of  vesical 
paralysis  causes  neither  marked  pain  nor  frequency  of 
micturition.^  Attacks  of  cystitis  in  a  man  with  calculus 
are  spoken  of  as  attacks  of  stone.  When  a  stone  is  small  it 
may  during  micturition  roll  into  the  urethral  orifice,  and  so 
cause  a  sudden  interruption  of  the  flow  of  water,  the  stream 
again  starting  when  the  patient  changes  his  position.  This 
symptom  is  rare  in  the  old,  the  stone  in  them  dropping  into 
the  sac  back  of  the  prostate  and  below  the  urethral  orifice. 
Hematuria  may  or  may  not  be  noted ;  it  is  most  usual  after 
exercise,  and  occurs  at  the  end  of  the  urinary  act.     Pus  or 

^  American  Text-book  of  Surgery. 


DISEASES   OF  GENITO-URINARY  ORGANS.  793 

mucopus  will  be  observed  if  cystitis  occurs.  Priapism  occurs 
in  some  cases.  Pain  of  a  reflex  nature  may  be  felt  in  the 
rectum,  in  the  perineum,  or  in  some  distant  part. 

The  above  symptoms,  even  if  all  are  present,  do  not  prove 
that  an  individual  has  a  stone  in  the  bladder.  To  prove  the 
presence  of  a  stone,  it  must  be  touched  with  a  sound  and 
the  contact  must  be  felt  and  heard.  To  sound  a  patient,  have 
the  bladder  well  filled  with  water,  and  place  him  recumbent 
with  the  knees  drawn  up.  Never  sound  a  person  while  he 
is  standing,  because  of  the  danger  of  syncope.  In  an  ordi- 
nary case  use  a  sound  with  a  very  slight  curve ;  in  a  man 
with  hypertrophied  prostate  use  a  sound  with  a  short  and 
decided  curve.  The  caliber  of  a  stone-sound  is  No.  13 
French.  The  instrument  is  carefully  boiled  and  anointed  with 
glycerin.  Examine  the  entire  bladder  systematically,  and 
never  operate  unless  a  stone  be  both  heard  and  felt.  The 
stone  may  be  hard  to  find,  or  it  may  elude  the  instrument 
entirely  when  it  is  encysted,  when  it  rests  in  a  diverticulum, 
when  it  is  fixed  to  the  roof  or  anterior  wall  of  the  viscus,  or 
when  it  is  crusted  with  lymph  or  blood-clot.  In  doubtful 
cases  always  insist  on  a  second  examination,  giving  ether  if 
the  first  was  VQ.ry  painful.  Occasionally  a  small  stone  will 
be  found  by  using  a  Bigelow  evacuator,  the  current  causing 
the  calculus  to  knock  against  the  tube.  In  many  cases  stone 
in  the  bladder  may  be  detected  by  means  of  the  A-rays.  A 
stone,  when  it  is  detected,  should  always  be  measured  by  an 
arrangement  like  a  lithotrite.  The  composition  of  the  stone 
is  assumed  from  an  examination  of  fragments  which  pass  by 
the  urethra  or  which  adhere  to  the  measure.  Remember  that 
the  outer  layer  of  a  calculus  may  be  soft  phosphate  and  the 
inner  portion  may  be  the  harder  uric-acid,  urates,  or  oxalates. 
Examine  for  stone  in  females  with  a  straight  sound,  and  in 
cases  of  uncertainty  dilate  the  urethra  and  explore  the  bladder 
with  the  little  finger. 

Treatment. — In  people  predisposed  to  stone  (for  instance, 
by  lithemia)  the  physician  should  foresee  the  danger  and  essay 
to  antagonize  it.  Insist  on  the  urine  being  kept  dilute  by  the 
freest  use  of  water  and  of  milk,  and  reduce  to  a  minimum 
the  amount  of  alcohol,  meat,  sugar,  and  fat  which  is  taken. 
Let  the  patient  live  chiefly  on  green  vegetables,  salads,  bread, 
fruit,  eggs,  fish,  poultr)^,  w'eak  tea  or  coffee,  water,  milk,  and, 
if  desired,  a  little  red  wine.  Continued  purging  does  harm  by 
concentrating  the  urine,  though  a  laxative  may  be  employed 
w'hen  indicated.  Moderate  open-air  exercise  is  of  immense 
importance,  sunshine  and  fresh  air  being  Nature's  correctives 


794  MODERN  SURGERY. 

for  a  condition  of  imperfect  oxidation  power.  If  the  urine  be 
very  acid,  use  piperazin,  gr.  xv  to  gr.  xx  daily,  liquor  potassii 
citratis,  phosphate  of  sodium,  or  borocitrate  of  magnesium. 
If  the  urine  be  phosphatic,  order  mineral  acids  and  strychnin, 
or  what  seems  to  be  very  efficient,  urotropin.  Urotropin  is 
given  in  gr.  v  capsules  four  times  daily.  If  the  urine  be  filled 
with  oxalate,  use  the  mineral  acids  with  an  occasional  course 
of  phosphate  of  sodium.  Travel  and  rest  at  the  seaside  or  at 
some  spa  are  often  of  service  in  all  forms.  Always  endeavor 
to  prevent  cystitis,  and  treat  it  at  once  when  it  does  occur. 
When  a  stone  is  once  formed  it  is  an  idle  dream  to  think 
of  dissolving  it.  An  operation  must  be  done.  The  operation 
selected  depends  upon  the  age,  the  state  of  the  bladder  and 
the  prostate,  the  dilatability  of  the  urethra,  the  kidney  con- 
dition, the  size  and  composition  of  the  stone,  and  the  number 
of  calculi  present  (see  Operations  on  the  Bladder). 

Cystitis. — Inflammation  of  the  bladder  is,  as  a  rule,  a 
complication  of  some  other  disease  of  the  genito-urinary 
tract,  but  it  may  arise  from  cold  and  wet.  Traumatism  from 
a  catheter,  the  presence  of  a  stone,  the  spread  of  a  urethral 
inflammation,  pus  infection,  the  existence  of  tuberculosis  or 
cancer,  and  the  use  of  such  a  drug  as  cantharides,  may  pro- 
duce it.  It  appears  not  unusually  during  an  exanthematous 
fever  or  in  conditions  of  vesical  paralysis  ;  it  often  follows 
retention,  frequently  accompanies  enlarged  prostate  and  ure- 
thral stricture,  and  sometimes  arises  from  concentration  of 
urine  or  accompanies  bladder  growths.  Acute  cystitis  causes 
discoloration  and  swelling  of  the  bladder-walls,  and  there 
is  present  a  catarrhal  discharge  which  is  mixed  with  urinary 
elements,  serum,  mucus,  often  pus  and  epithelial  debris.  Ul- 
ceration, sloughing,  or  false-membrane  formation  may  occur. 
Chronic  cystitis  is  an  inflammatory  condition  always  due  to 
bacteria.  We  frequently  speak  of  a  chronic  cystitis  as  due  to 
stone  in  the  bladder,  hypertrophy  of  the  prostate  gland,  or 
tumor  of  the  bladder.  These  conditions  do  not  cause 
chronic  cystitis,  but  act  by  rendering  the  bladder  vulnerable 
to  micro-organisms.  Among  the  causative  organisms  we 
may  mention  the  bacillus  coli  communis,  the  gonococcus, 
the  bacillus  tuberculosis,  the  bacillus  typhosis,  and  the 
various  pyogenic  bacteria  (Leonard  Freeman). 

In  chronic  cystitis  there  is  an  enormous  production  of 
thick,  sticky  mucus  and  the  urine  becomes  alkaline.  The 
excessive  secretion  of  mucus  and  the  great  number  of 
bacteria  convert  the  urea  into  carbonate  of  ammonium,  and 
this  production,  being  irritant  to  the  bladder-walls,  makes 


DISEASES   OF  GENITO-URINARY  ORGANS.  795 

the  inflammation  worse.  In  chronic  cystitis  the  bladder  is 
contracted  and  has  very  thick  walls,  and  the  mucous  mem- 
brane is  thick,  edematous,  congested,  and  filled  with  large 
veins.  The  bladder  may  be  ulcerated  or  be  encrusted  with 
urinary  salt.  The  urine  contains  bacteria,  triple  phosphate, 
pus,  blood,  and  mucus,  the  blood  emerging  with  the  last  drops 
of  water.     Pyelitis  may  arise  as  a  result  of  chronic  cystitis. 

Symptoms  of  Acute  Cystitis. — Great  frequency  of  mic- 
turition, with  the  passage  at  each  act  of  a  very  small  quan- 
tity of  urine ;  the  desire  to  urinate  is  almost  constant,  and 
there  is  intensely  painful  straining  (tenesmus).  The  pain  is 
acute  and  scalding,  and  may  be  felt  above  the  pubes  or  in 
the  perineum ;  it  often  runs  into  the  loins  and  the  thighs 
and  radiates  over  the  sacrum.  Pain  above  the  pubes  indi- 
cates involvement  of  the  fundus,  and  pain  in  the  perineum 
and  in  the  head  of  the  penis  points  to  inflammation  of  the 
bladder-neck.  The  urine,  at  first  clear,  loses  its  transparency, 
becomes  full  of  thick  mucus,  and  often  contains  a  little  blood 
or  pus.  The  patient  not  unusually  has  some  fever.  A  rectal 
examination  causes  violent  pain.  If  ischuria  takes  place,  there 
will  be  a  chill  and  high  fever,  and  anuria  may  occur  or  vesical 
rupture  may  ensue. 

Treatment. — In  treating  acute  cystitis  try  to  remove  the 
cause.  If  cystitis  arises  from  the  administration  of  canthar- 
ides,  put  the  patient  in  bed  and  give  him  liquor  potassii 
citratis.  If  it  comes  from  the  use  of  a  clean  sound,  order 
rest  in  bed,  suppositories  of  opium  and  belladonna,  diluent 
drinks,  and  the  use  of  ammonii  benzoas  or  of  lupulin.  If 
the  inflammation  is  septic  (as  from  the  use  of  a  dirty  sound), 
or  is  very  acute,  put  the  patient  in  bed,  keep  him  warm,  and 
use  a  hot  sand-bag  to  the  perineum  and  hot  fomentations  or 
poultices  to  the  hypogastrium.  Hot  hip-baths  may  be  used. 
The  hips  had  best  be  elevated  and  the  bowels  be  emptied  by 
salines  and  glycerin  enemata.  An  exclusive  milk-diet  is 
desirable.  The  patient  should  drink  copiously  of  sweetened 
water  containing  a  few  drops  of  aromatic  sulphuric  acid  or 
of  milk  of  almonds.  An  excellent  remedy  is  the  combina- 
tion of  equal  parts  of  the  infusion  of  herba  herniare  and 
chenopodium  ambrosioides.  three  glassfuls,  sweetened  with 
sugar,  being  given  every  day  (v.  Zeissl).  If  the  pain  and 
straining  still  continue,  order — 

R.  Ext.  sem.  hyoscyamin.,  grs.  viij ; 

Ext.  cannabis  indicse,  grs.  viij ; 

Sacchar.  alba,  grs.  xlviij. — M. 
Div.  in  pulv.  No.  xx. 
Sig.  One  powder  every  three  hours.  (Von  Zeissl.) 


796  '       MODERN  SURGERY. 

Or, 

R.  Camphora,  grs.  viij ; 

Ext.  cannabis  indicse,  grs.  viij ; 

Sacchar.  alba,  grs.  xlviij. — M. 

Div.  in  piilv.  No.  xx. 
Sig.  One  powder  every  three  hours.  (Von  Zeissl.) 

Suppositories  of  extract  of  belladonna  are  of  great  value. 
Suppositories  each  containing  gr.  j  of  ichthyol  are  of  service ; 
and  one  should  be  used  every  four  hours.  If  these  remedies 
fail,  the  surgeon  will  be  driven  to  opium,  which,  unfortu- 
nately constipates ;  when  it  is  used,  secure  evacuations  by 
glycerin  suppositories  or  by  enemata.  Give  a  suppository 
containing  gr.  j  of  powdered  opium  and  gr.  \  of  the  extract 
of  belladonna  every  three  or  four  hours.  Hypodermatic  in- 
jections of  morphin  may  be  required.  If  retention  occurs, 
use  a  soft  catheter.  If  much  blood  is  passed,  give  internally 
the  tinctura  ferri  chloridi  and  blister  the  perineum,  A  very 
acute  cystitis  is  rarely  arrested  within  a  week  or  ten  days. 

Symptoms  of  Chronic  Cystitis. — This  condition  may  be 
a  legacy  from  acute  cystitis,  or  it  may  appear  without  any 
acute  precursory  phenomena.  There  will  be  found  frequency 
of  micturition,  but  not  so  great  as  in  the  acute  form ;  there 
will  be  slight  tenesmus,  and  moderate  pain  from  time  to  time, 
running  toward  the  head  of  the  penis.  Constitutional  symp- 
toms arise  only  when  kidney-damage  has  become  pronounced 
or  sepsis  has  occurred  from  absorption.  The  urine  is  ammo- 
niacal,  fetid,  and  turbid;  it  is  filled  with  viscid,  tenacious 
mucus  or  with  muco-pus ;  it  contains  a  great  excess  of 
phosphates,  and  occasionally  clots  of  blood.  The  condition 
of  chronic  cystitis  with  the  production  of  immense  quanti- 
ties of  thick  mucus  is  often  called  "  chronic  catarrh  of  the 
bladder."  This  state  of  the  bladder  may  eventuate  in  the 
formation  of  stone  or  in  the  production  of  serious  diseases 
of  the  bladder,  the  ureters,  and  the  kidneys.  It  often  occa- 
sions retention.  Chronic  cystitis  may  be  due  to  tuberculosis. 
Some  cases  come  on  suddenly,  many  tubercle  bacilli  being 
found  in  the  urine.  In  many  cases  no  tubercle  bacilli  are 
found.  The  tubercular  products  caseate  or  fibrous  organi- 
zation takes  place.  A  cystitis  for  which  no  cause  can  be 
found,  and  which  is  accompanied  by  pyuria  and  pain,  is 
possibly  tubercular.  The  cystoscope  in  these  cases  should 
only  be  used  by  an  expert. 

Treatment. — In  treating  chronic  cystitis  remove  the  cause 
if  possible,  get  rid  of  a  stone,  evacuate  residual  urine  fre- 
quently, dilate  a  stricture,  and  remove  a  tumor.    For  chronic 


DISEASES   OF  GEXITO-URINARY  ORGANS.  797 

cystitis  there  are  used  certain  remedies  by  the  mouth.  Water 
is  drunk  in  large  amounts,  also  iron  spring-water  (Marienbad, 
etc.).  Salol  and  boric  acid,  gr.  v  of  each  four  times  a  day, 
are  very  valuable.  Salol  in  fluid  extract  of  triticum  repens 
does  good;  so  does  chlorate  of  potassium,  gr.  x  daily.  Alum, 
tannic  acid,  uva  ursi,  copaiba,  cubebs,  buchu,  and  turpen- 
tine have  all  been  recommended,  and  possibly  may  be  of 
some  benefit.  Urotropin  is  useful  in  cases  of  chronic  cyst- 
itis. This  drug  prevents  the  development  of  bacteria  in  the 
urine  (Nicolaier),  and  antagonizes  the  tendency  to  sepsis  and 
urinary  poisoning.  It  is  given  in  5 -grain  capsules,  from  four 
to  six  being  giv^en  daily.  Whatever  remedy  is  used,  see  that 
the  bowels  move  once  a  day,  and  that  the  skin  is  active. 
Champagne  and  beer  must  be  avoided  in  chronic  cystitis. 
If  residual  urine  gathers,  a  soft  catheter  must  be  regularly 
used.  If  it  is  possible  to  introduce  a  catheter  of  consider- 
able size,  catheterization  may  be  all  that  is  needed  in  the  case. 
If  it  is  not  possible,  or  if  the  case  is  very  severe,  the  bladder 
must  be  washed  out  daily  with  peroxid  of  hydrogen  (25  to 
40  per  cent,  solution),  nitrate  of  silver  (i  :  8000),  boric  acid 
(5  to  10  per  cent),  carbolic  acid  (i  :  500),  corrosive  sublimate 
(from  I  :  5000  to  i  :  20,000),  or  permanganate  of  potassium 
( I  to  4000).  If  nitrate  of  silver  or  permanganate  of  potassium 
is  used,  first  rinse  out  the  bladder  with  distilled  water.  If  any 
other  agent  is  used,  wash  out  the  bladder  with  boiled  water. 
The  daily  injection  of  a  2  per  cent,  solution  of  ichthyol  may 
prove  useful.  Some  surgeons  occasionally  employ,  at  intervals 
of  a  number  of  days,  strong  silver  solutions  (30  or  40  grains 
to  the  ounce).  If  a  strong  solution  is  used,  after  the  drug  flows 
out  wash  out  the  bladder  with  a  solution  of  common  salt. 
The  bladder  is  usually  washed  out  by  attaching  to  the  free 
end  of  a  soft  catheter,  the  other  end  of  which  is  in  the  blad- 
der, a  tube  which  is  connected  with  a  graduated  bottle,  the 
force  being  obtained  by  elevating  the  reservoir  (fountain 
irrigation).  The  bladder  can  be  irrigated  without  using  a 
catheter,  the  resistance  of  the  compressor  muscle  of  the 
urethra  being  overcome  by  the  pressure  of  a  column  of 
water.  The  reservoir  is  raised  to  the  height  of  six  feet. 
The  patient  sits  in  a  chair.  The  tube  of  the  reservoir  has 
upon  it  a  clamp  to  control  the  flow,  and  in  its  end  a  large 
bulbous  tip  which  will  fill  the  meatus.  The  tip  is  inserted 
into  the  urethra,  the  clamp  on  the  tube  is  loosened,  and  the 
patient  is  directed  to  take  a  deep  inspiration.  In  a  short 
time  the  bladder  fills  with  water,  the  tube  is  removed,  and 
the  patient  empties  the  viscus  naturally  (Felick).     In  some 


798  MODERN  SURGERY. 

cases  it  is  necessary  to  wait  quite  a  while  for  the  column  of 
water  to  tire  out  the  muscle.  If  the  fluid  will  not  enter, 
direct  the  patient  to  urinate,  and  then  make  another 
attempt.  After  a  little  practice  a  patient  learns  how  to 
admit  the   fluid. 

In  tubercular  cystitis  ColHn  advises  the  instillation  of  the 
following  mixture  into  the  bladder  and  posterior  urethra: 
5  gm.  of  guaiacol,  i  gm.  of  iodoform,  100  gm.  of  sterile  olive 
oil.  About  30  minims  of  this  are  injected  (1.2  c.c.)  once  a 
day.  In  ordinary  non-tubercular  cystitis  he  uses  a  i  per  cent, 
solution  in  oil  of  guaiacol  carbonate.  If  these  methods  fail 
to  improve  a  chronic  cystitis  and  the  patient's  health  is 
breaking  down,  drain  by  perineal  or  suprapubic  cystotomy 
(see  Perineal  Section,  page  736)  and  through  the  incision 
wash  the  bladder  frequently  and  thoroughly. 

Tumors  of  the  Bladder. — These  tumors  may  be  either 
innocent  or  mahgnant,  the  latter  being  the  commonest. 
Innocent  tumors  are  papillomata  or  villous  tumors,  mucous 
polypi,  and  fibrous  polypi ;  malignant  tumors  are  sarcoma 
(rare)  and  carcinoma,  encephaloid  (rare),  epithelioma  (com- 
mon). 

Symptoms. — The  innocent  tumors  rarely  cause  cystitis  or 
irritation,  though  by  obstructing  the  ureters  or  the  urethra 
they  may  induce  disease  of  the  kidneys.  Often  hemorrhage 
is  the  only  phenomenon  produced  by  a  papilloma  or  a 
mucous  polyp.  Malignant  tumors  cause  cystitis,  and  the 
urine  contains  mucus,  blood,  and  pus.  Innocent  tumors  are 
hard  to  feel  with  the  sound,  but  malignant  tumors  are  easily 
felt.  In  some  cases  a  tumor  can  be  detected  by  a  bimanual 
examination  (a  finger  in  the  rectum  and  the  fingers  of  the 
other  hand  on  the  abdomen).  Make  a  careful  study  to 
determine  whether  or  not  growth  has  infiltrated  the  pros- 
tate, the  seminal  vesicles,  the  rectum,  or  the  perivesical  tis- 
sues. The  bleeding  in  bladder-growths  is  apt  to  be  profuse, 
and  it  occurs  intermittently.  Bleeding  follows  the  use  of  a 
sound.  The  urine  should  be  examined  microscopically  to 
see  if  it  contains  villi,  portions  of  fibroma,  colonies  of  cancer- 
cells,  or  fragments  of  epithelioma  (White).  A  cystoscope 
should  be  employed  in  order  to  reach  a  diagnosis.  In 
doubtful  cases  exploratory  suprapubic  cystotomy  is  advis- 
able. 

The  treatment  is  by  suprapubic  cystotomy  and  removal 
of  the  growth.  The  perineal  operation  only  enables  the 
surgeon  to  reach  and  remove  growths  of  small  size,  pedun- 
culated growths,  and  growths  near  the  neck  of  the  bladder 


DISEASES    OE   GENITO-URINARY  ORGANS.  799 

(sec  Operations  on  the  Bladder).  Chismore  has  suggested 
the  removal  of  polypoid  growths  by  means  of  Bigelow's 
evacuator.  When  the  growth  catches  in  the  eye  of  the 
instrument  it  is  torn  off  by  slight  traction  and  gentle  rock- 
incr  and  the  suction  which  is  being  made  carries  it  into  the 
reser\'oir. 

Operations  on  the  Bladder. — Lateral  Lithotomy. — 
LitJiotoviy  is  the  remoxal  of  a  stone  from  the  bladder. 
Lateral  lithotomy  is  an  operation  which  is  ever)'  )'ear  be- 
coming less  popular,  but  which  is  still  employed  by  many 
famous  surgeons,  especially  for  stone  in  children.  This 
operation  should  not  be  performed  if  the  stone  is  over  tw^o 
inches  in  its  short  diameter;  it  is  rarely  justifiable  if  the 
stone  weighs  three  ounces  or  more  (Cage) ;  and  it  must  not 
be  performed  for  encysted  stone,  or  on  a  person  with  a  deep 
perineum,  a  narrow  pelvic  outlet,  or  an  enlarged  prostate. 
For  one  week  before  the  operation  keep  the  patient  in  bed, 
wash  out  the  bladder  daily  with  hot  boric-acid  solution,  and 
administer  salol  and  boric  acid  by  the  mouth,  gr.  v  of  each 
four  times  a  day.  The  night  before  the  operation  give  a 
saline,  order  a  hot  bath,  and  have  the  perineum,  the  scrotum, 
the  buttocks,  and  the  inner  sides  of  the  thighs  cleansed  and 
dressed  antiseptically.  In  the  morning  an  enema  is  to  be 
given.  At  the  time  of  operation  the  bladder  should  contain 
several  ounces  of  urine.  The  instruments  required  are  a  lith- 
otomy-knife, a  straight  probe-pointed  bistoury,  a  grooved 
staff,  a  stone-sound,  stone-forceps  and  scoops,  a  tenaculum, 
an  aneurysm-needle,  a  fountain  syringe,  curved  needles  and 
a  needle-holder,  hemostatic  forceps,  a  tube  with  chemise 
(Fig.  52),  a  Paquelin  cautery,  a  Clover  crutch,  and  a  litho- 
trite. 

In  performing  the  operation,  place  the  patient  upon  his 
back  and  find  the  stone  by  sounding.  If  the  stone  is  not  dis- 
covered by  the  sound,  do  not  operate.  Place  the  buttocks  so 
that  they  project  beyond  the  edge  of  the  table,  introduce  the 
staff  into  the  bladder,  flex  the  legs  and  thighs,  and  fasten 
the  patient  in  the  lithotomy  position  with  a  crutch.  During 
the  first  incision  the  handle  of  the  staff  is  held  toward  the 
belly ;  after  the  first  cut  the  staff  is  set  perpendicularly  and 
is  hooked  up  under  the  pubes.  An  incision  is  made,  start- 
ing just  to  the  left  of  the  raphe  of  the  perineum  and  one 
and  a  quarter  inches  in  front  of  the  edge  of  the  anus,  and 
passing  downward  and  outward  to  between  the  anus  and  the 
ischial  tuberosity,  but  one-third  nearer  the  former  than  the 
latter.     In  the  adult  this  incision  is  three  inches  lon^.     The 


8oO  MODERN  SURGER  V. 

first  incision  is  superficial  and  does  not  reach  the  staff,  but 
it  is  this  incision  which  may  cut  the  rectum.  After  makings 
the  first  cut  the  nail  of  the  left  index  finger  feels  for  the 
groove  of  the  staff,  the  staff  is  hooked  up,  the  knife  is 
entered  into  the  groove  and  is  pushed  into  the  bladder,  and 
as  it  is  withdrawn  the  wound  is  enlarged.  As  the  knife 
enters  the  bladder  there  is  a  gush  of  fluid.  The  finger  fol- 
lows the  knife  and  stretches  the  wound,  the  staff  is  with- 
drawn, and  the  stone  is  felt  for  and  extracted  with  forceps. 
Lister  showed  years  ago  the  value  of  keeping  the  finger  in 
the  wound.  This  maneuver  retains  some  water  in  the  blad- 
der, and  as  a  consequence  causes  the  stone  to  rest  at  the 
lowest  part  of  the  viscus,  and  when  the  forceps  are  in- 
troduced they  at  once  come  upon  the  stone.  In  with- 
drawing the  stone  make  traction  in  the  axis  of  the  pelvis, 
and  do  not  rotate  the  calculus  until  it  is  entirely  out  of 
the  prostatic  urethra.  Wash  or  scrape  away  debris  or 
incrustation,  see  that  no  other  stone  is  present,  syringe 
out  the  bladder  with  hot  salt  solution,  insert  a  tube, 
apply  antiseptic  dressings  around  the  tube,  and  put  on 
a  T-bandage.  The  end  of  the  tube  which  is  external  to 
the  dressings  is  fastened  to  the  tails  of  the  T-bandage. 
A  rubber  cloth  is  put  on  the  bed,  under  the  body  and 
legs,  and  the  patient's  buttocks  rest  upon  a  mass  of  old 
linen,  the  scrotum  being  raised  on  a  pad.  The  knees  are 
bent  over  pillows.  Change  the  linen  as  soon  as  it  becomes 
wet.  Remove  the  tube  in  forty-eight  hours.  The  urine 
begins  to  come  by  the  urethra  from  the  eighth  to  the  twelfth 
day.  In  children  the  incision  is  not  so  long,  and  is  dilated 
with  forceps  instead  of  with  the  finger ;  no  tube  is  required. 
In  lateral  lithotomy  the  prostatic  and  membranous  portions 
of  the  urethra  are  opened,  the  prostate  gland  is  partly 
divided  with  the  knife,  and  the  wound  is  dilated  with  the 
finger. 

Suprapubic  Lithotoniy. — This  operation  is  the  removal 
of  a  stone  through  an  opening  over  the  pubes.  It  is  in  many 
instances  the  preferable  operation.  It  is  used  for  the  removal 
of  multiple  calculi,  for  very  hard  stones,  for  stones  above 
one  and  a  half  inches  in  diameter,  for  calculi  in  men  with 
enlargement  of  the  prostate,  for  foreign  bodies  incrusted  with 
sediment,  Avhen  the  perineum  is  deep,  when  the  pelvic  outlet 
is  narrow,  and  when  the  urethra  will  not  permit  the  use  of 
a  lithotrite.  The  patient  is  prepared  as  for  lateral  lithotomy, 
except  that  the  pubes  are  shaved,  and  the  lower  part  of  the 
abdomen  and  the  upper  part  of  the  thighs  are  disinfected. 


DISEASES   OF  GENITOURINARY  ORGANS.  8oi 

During  the  operation  the  penis  is  wrapped  with  a  piece  of 
antiseptic  gauze.  The  instruments  required  are  a  scalpel, 
a  probe-pointed  bistoury,  scissors,  a  tenaculum,  blunt  hooks, 
hemostatic  forceps,  retractors,  dissecting-forceps,  a  dry  dis- 
sector, an  electric  forehead-light,  a  rectal  bag,  a  brass  syringe 
or  a  bicycle-pump,  a  sound,  rubber  tubing,  rubber  catheters, 
stone-forceps  and  scoops,  a  bladder-tube,  curved  needles  and 
a  needle-holder,  and  a  graduated  glass  jar  for  injecting  the 
bladder. 

In  performing  the  operation  place  the  patient  in  the  Tren- 
delenburg position.  It  is  necessary  to  distend  the  bladder 
and  raise  it  in  order  to  have  a  prevesical  space  uncovered 
by  peritoneum.  Have  an  assistant  oil  the  rectal  bag  and 
push  it  above  the  sphincters.  Draw  off  the  urine  with  a  soft 
catheter,  wash  out  the  bladder  with  warm  boric-acid  solution 
(i  :  32),  and  inject  the  bladder  with  the  same  solution.  In  a 
child  under  the  age  of  five  inject  three  to  four  ounces ;  in  an 
adult  inject  ten  to  twelve  ounces.  Withdraw  the  catheter 
and  tie  a  tube  around  the  penis  to  prevent  the  escape  of  fluid. 
Bristow  suggested  the  injection  of  air.  Some  surgeons 
simply  inject  air  by  means  of  a  catheter  and  a  brass  syringe 
or  a  Davidson  syringe.  If  air  is  injected,  a  rectal  bag  is 
not  used,  and  the  patient  is  placed  on  his  back  rather  than 
in  the  position  of  Trendelenburg.  The  best  method  of  in- 
jecting air  is  that  of  F.  Tilden  Brown,  by  means  of  a  bicycle- 
pump.  A  catheter  is  introduced,  the  bladder  is  washed  out, 
the  catheter  is  fastened  to  a  bandage,  the  bicycle-pump  is 
attached,  the  operation  is  proceeded  with,  and  when  the 
transversalis  fascia  is  exposed  the  bladder  is  filled  with  air, 
the  soft  catheter  is  clamped,  and  the  bladder  is  opened.' 
After  injecting  the  bladder  with  fluid,  if  the  viscus  is  not  well 
lifted,  inject  the  rectal  bag  with  water  and  clamp  its  tube  with 
forceps.  In  a  child  inject  from  two  to  four  ounces  of  warm 
water  into  the  rectal  bag;  in  an  adult  inject  ten  ounces.  Make 
a  three-inch  longitudinal  incision  in  the  median  line  of  the  hy- 
pogastric region,  terminating  over  the  symphysis.  When  the 
perivesical  connective  tissue  is  reached,  cut  it.  If  the  peri- 
toneum should  appear,  push  it  up.  Hold  the  wound-edges 
apart  by  retractors.  The  large  veins  are  seen,  giving  the 
bladder  a  blue  color.  Avoid  these  veins  if  possible,  but  even 
if  they  should  be  cut  bleeding  will  stop  when  the  bladder  is 
opened  and  the  rectal  bag  is  removed.  Clamp  bleeding  ves- 
sels ;  catch  the  bladder  transversely  with  a  tenaculum  at  the 
upper  angle  of  the  wound  ;  open  the  viscus  in  the  middle  line 

^  F.  Tilden  Brown,  Annals  of  Surgery,  Feb.,  1897. 
51 


802 


MODERN  SURGERY. 


above,  and  cut  toward  the  pubes ;  catch  the  edges  of  the  bladder 
with  hemostatic  forceps,  and  remove  the  tenaculum.  Explore 
the  bladder,  remove  the  stone  or  stones,  scrape  away  incrus- 
tations, ligate  bleeding  vessels  outside  the  bladder,  and  irrigate 
the  viscus  with  hot  sahne  solution.  Introduce  a  tube  into 
the  bladder,  and  attach  to  its  external  end  a  long  tube  to 
siphon  off  the  urine.  The  bladder  can  be  drained  very 
satisfactorily   by   Keen's    siphonage    apparatus    (Fig.    292). 


Fig.  292. — Keen's  siphonage  apparatus  :  X,  cavity  to  be  drained  ;  A,  reservoir ;  K,  tube 
from  cavity  ;  B,  tube  from  reservoir;  H,  clamp  on  tube  from  reservoir;  Z,,  i^, /?,  glass  tubes; 
C,  rubber  tube  connecting  cavity-drain  with  reservoir-drain ;  E,  S-shaped  rubber  tube  main- 
tained in  shape  by  hooking  up  ai  F :   G,  vessel  containing  antiseptic  fluid. 

Suture  the  muscles  and  fascia  at  the  upper  part  of  the 
wound.  Dress  with  dry  antiseptic  gauze  and  a  rubber- 
dam,  the  dressings  and  binder  being  split  to  go  around  the 
tube.  Catch  the  urine  which  siphons  over  in  a  bottle  con- 
taining some  antiseptic  fluid.  Change  the  dressings  as  often 
as  they  become  wet  Take  out  the  tube  in  four  or  five  days, 
and  allow  the  wound  to  heal  by  granulation.  The  patient 
may  get  up  in  two  weeks.  Many  Continental  surgeons  advo- 
cate immediate  suture  of  the  bladder  after  incision.  The 
suture-material  should  be  silk  or  catgut.  Albert,  Vincent, 
Bassini,  DeVlaccos,  and  others  advocate  immediate  suture. 
After  suture  a  catheter  is  kept  in  the  bladder  to  drain  the  viscus. 
Immediate  suture  may  be  employed  in  patients  of  any  age,  but 


DISEASES   OF  GENITOURINARY  ORGANS. 


803 


should  not  be  used  if  the  urine  is  very  septic  or  if  pyeloneph- 
ritis exists.  In  some  cases  the  attempted  closure  will  fail ; 
in  others  it  will  only  partially  succeed ;  in  the  majority  it  will 
prove  successful ;  but  even  if  it  only  partially  succeeds  it  will 
tend  to  prevent  dissemination  of  urine  in  the  prevesical  cellu- 
lar tissue. 

Crushing  of  Vesical  Calculi. — This  is  now  done  in  one 
sitting,  the  old  operation  of  Civiale,  requiring  repeated  crush- 
ings,  being  obsolete. 

Litholapaxy  (Bigelow's  operation,  or  rapid  lithotrity)  is 
the  operation  for  removing  a  stone  in  the  bladder  in  one  sit- 


FiG.  293. — Bigelow's  latest  evacuator. 

ting  by  thoroughly  crushing  the  stone  and  completely  wash- 
ing away  the  fragments.  Sir  H.  Thompson  says  this  method 
is  suited  to  twenty-nine  cases  out  of  thirty.  Litholapaxy 
should  be  employed  if  the  bladder  will  hold  at  least  six 
ounces  of  fluid  and  is  in  a  fairly  healthy  condition  ;  if  the 
urethra  is  tolerant  and  penetrable  by  instruments ;  if  the 
stone  is  not  too  hard,  does  not  weigh  over  two  and  three- 
quarters  ounces,  and  is  not  over  two  inches  in  diameter.  It 
is  not  suited  for  multiple  calculi,  for  large  and  hard  calculi, 
for  encysted  stones,  or  for  a  patient  with  enlarged  prostate, 
with  vesical  atony,  or  with  cystitis.  An  easily  dilatable  strict- 


8o4 


MODERN  SURGERY. 


ure  need  not  prevent  the  surgeon  from  doing  litholapaxy. 

The  stricture  can  first  be  dilated,  and  later  Bigelow's  opera- 
tion can  be  performed,  but  firm,  gristly  strict- 
ures demand  a  cutting  operation.  If  the  ure- 
thra is  intolerant  of  instrumentation,  the  pa- 
tient being  prone  to  febrile  attacks  when  it  is 
attempted,  cut  instead  of  crushing.  People 
with  kidney  disease  will  do  better  after  this 
operation  than  after  cutting  (Cage).  In  dia- 
betes, locomotor  ataxia,  and  conditions  of 
exhaustion  patients  are  best  treated  by  Bige- 
low's operation,  unless  cystitis  exists. 


Fig.  294. — Bigelow's 
lithotrite. 


Fig.  295.  — Thompson's  Fig.  296. — Forbes's 

lithotrite.  lithotrite. 


The  preparation  of  the  bladder  is  the  same  as  for  Hth- 
otomy.      Be   sure  to  measure  the  stone,  and  to  ascertain 


DISEASES   OF  GENITO-URINAKY  ORGANS. 


805 


also  whether  a  hthotrite  can  readily  be  introduced  and  ma- 
nipulated. The  instruments  required  are  a  stone-sound, 
lithotrites  (several  sizes)  (Figs.  294-296),  an  evacuating-bulb 
and  tubes  (straight  and  curved)  (Figs.  293,  297),  soft  catheters, 
a  glass  irrigator  to  inject  the  bladder,  and  instruments  in  case 
the  surgeon  is  forced  to  cut.  The  patient  is  anesthetized 
and  is  placed  upon  his  back,  a  pillow  is  inserted  under 
the  pelvis  and  he  is  well  wrapped  up.  The  urine  is  drawn 
and  a  measured  amount  of  warm  boric  acid  is  allowed  to 
flow  into  the  bladder.  This  plan  is  better  than  having 
the  patient  retain  his  urine,  as  in  the  latter  case  there  is 
no  certainty  as  to  the  amount  of  fluid  in  the  viscus.  It  is 
well  to  introduce  at  least  five 
or  six  ounces  of  fluid  if  pos- 
sible. If  the  bladder  will  not 
hold  four  ounces  the  opera- 
tion is  unsafe  (Thompson). 
The  Hthotrite  is  now  intro- 
duced, the  handle  being  grad- 
ually raised  to  a  vertical  posi- 
tion as  the  penis  is  drawn 
up  on  the  shaft,  but  not 
being  depressed  until  the 
instrument  has  passed  by  its 
own  weight  into  the  prostatic 
urethra.  Thompson's  plan 
for  catching  the  stone  is  as 
follows :  after  introducing 
the  Hthotrite,  let  its  lower 
end  rest  for  a  few  seconds 
on  the  bottom  of  the  blad- 
der, so  that  currents  will 
subside  ;  then  draw  back  the 
male  blade,  wait  a  moment, 
close  the  blades,  and  in  al- 
most every  instance  the  stone  ^'^  297.-Thompson-.  evacuator. 
will  be  caught.  If  the  stone  is  caught,  press  firmly  to  see  that 
the  calculus  is  well  held,  lock  the  instrument,  and  break  the 
foreign  body  by  screwing.  When  resistance  suddenly  ceases 
the  stone  has  either  slipped  or  has  been  crushed ;  if  crushed, 
the  blades  should  have  been  felt  forcing  through  the  stone 
and  the  calculus  should  have  been  heard  to  break.  When 
resistance  ceases  catch  and  crush  again  as  above  directed. 
Rapid  movements  with  the  Hthotrite  are  improper,  as  they 
establish  currents  which  are  apt  to  push  away  the  stone.     If 


8o6  MODERN  SURGERY. 

the  above  maneuver  does  not  catch  the  stone,  see  if  the  cal- 
culus be  near  the  neck  of  the  bladder.  Pull  the  instrument 
close  to  the  vesical  neck,  and  open  it,  not  by  pulling  the  male 
blade,  but  by  pushing  the  female  blade.  If  the  operator  still 
fails  to  catch  the  stone,  or  if,  after  crushing,  a  large  fragment 
knocks  against  the  evacuator,  which  fragment  cannot  pass, 
conduct  a  careful  search :  turn  the  blades  to  the  right  side, 
open,  and  close ;  then  to  the  left  side,  open,  and  close ;  next 
turn  the  point  around  behind  the  prostate,  open,  and  close. 
In  these  side  turns  of  the  lithotrite,  in  order  to  crush,  turn 
the  instrument  very  slowly,  so  as  to  detect  the  catching  of 
the  bladder-wall  if  it  has  occurred,  and  crush  the  stone  in 
the  middle  of  the  bladder  with  the  blades  up.  After  crushing 
several  times,  proceed  to  evacuate.  Fill  the  aspirator  with 
warm  saHne  fluid.  Insert  an  evacuating  catheter,  its  point 
being  in  the  center  of  the  bladder,  let  the  fluid  and  fragments 
run  out,  and  attach  the  aspirator  to  the  catheter ;  turn  the 
valve,  and  compress  and  relax  the  bulb  so  that  an  ounce  or 
more  of  fluid  is  forced  in  at  each  squeeze,  the  compression 
coinciding  with  expiration.  The  debris  falls  into  a  bulb, 
and  the  pumping  is  continued  until  fragments  cease  to  pass, 
whereupon  the  point  of  the  catheter  is  pushed  against  the 
floor  of  the  bladder  and  another  trial  is  made.  If  fragments 
which  cannot  gain  exit  are  felt  knocking  against  the  tube, 
withdraw  the  evacuator,  crush  again,  and  again  use  the  aspi- 
rator. When  no  more  debris  comes  away  and  no  more  frag- 
ments are  felt,  withdraw  the  tube  and  carefully  sound  the 
bladder.  Keyes  advises  the  operator  to  seek  for  a  final  frag- 
ment by  listening  with  a  stethoscope  while  pumping  at  the 
bulb  and  searching  the  bladder  with  the  tube.  This  operation 
will  rarely  occupy  over  forty  minutes,  though  Bigelow  has 
protracted  it  for  three  hours,  the  patient  recovering.  A  seri- 
ous complication  is  severe  bleeding,  due  to  damage  done 
with  the  instrument  or  to  the  presence  of  a  tumor  which 
easily  bleeds.  The  injection  of  moderately  hot  water  usually 
checks  hemorrhage,  but  if  bleeding  is  dangerous  in  amount 
the  operation  of  litholapaxy  should  be  abandoned  and  a 
suprapubic  lithotomy  be  performed. 

If  clogging  of  the  lithotrite  with  fragments  occurs, 
forcible  pushing  of  the  blades  together  repeatedly  will 
probably  amend  it ;  but  it  will  never  happen  if  the  sur- 
geon uses  a  proper  form  of  instrument.  A  lithotrite  with  a 
fenestrated  blade  will  not  lock.  Forbes's  lithotrite  is  a 
very  powerful  instrument,  the  blades  of  which  will  not  lock. 
If  the  blades  of  a   lithotrite   should    become  forcibly  and 


DISEASES   OF  GENITO-URINARY  ORGANS.  807 

hopelessly  locked,  make  a  perineal  section,  clear  out  the 
blades,   close  them,  and   then  withdraw  the  instrument. 

Aftcr-trcatmciit. — Put  the  patient  to  bed,  apply  a  bag  of 
hot  water  to  the  hypogastrium,  and  give  him  a  hypodermatic 
injection  of  morphin  as  he  recovers  from  ether.  Give  a  hot 
hip-bath  every  night,  and  administer  liquor  potassii  citratis 
in  moderate  doses  every  day.  If  urethral  fever  occurs  use 
quinin  and  morphin,  wash  out  the  bladder  several  times  daily 
with  warm  boric-acid  solution,  and  tie  in  a  rubber  catheter. 
If  retention  occurs  use  the  catheter.  If  cystitis  appears 
treat  as  in  an  ordinary  case.  The  urine  ceases  to  be 
bloody  in  two  or  three  days,  and  the  patient  may  get  up 
in  a  week. 

Litholapaxy  in  Male  Children. — It  was  considered  until 
quite  recently  that  a  child,  because  of  the  small  size  of  its 
bladder,  the  small  diameter  of  the  urethi'a,  and  the  readiness 
with  which  the  mucous  membrane  is  lacerated  by  even 
slight  violence,  was  a  bad  subject  for  crushing.  Lateral 
lithotomy  is  known  to  be  eminently  successful  when  per- 
formed upon  children.  The  elder  Gross  did  this  oper- 
ation upon  72  children  with  only  2  deaths.  Keegan,  how- 
ever, has  persuaded  the  profession  that  rapid  lithotrity 
is  perfectly  applicable  to  children :  he  shows  that  the 
bladder  of  a  child  of  even  less  than  two  years  of  age  is 
quite  large  enough  to  allow  the  surgeon  to  manipulate  an 
instrument,  that  the  mucous  membrane  is  in  no  danger  if 
the  operator  be  careful,  and  that  the  urethra  is  by  no  means 
so  small  as  was  supposed.  The  urinary  meatus  must  often 
be  incised,  and  after  doing  this,  Keegan  states,  there  can  be 
passed  in  a  boy  of  from  three  to  six  years  a  No.  7  or  8 
lithotrite  (English),  and  in  a  boy  of  from  eight  to  ten  years 
a  No.  10  or  even  a  No.  14.  It  is,  however,  just  to  state 
that  the  operation  is  more  delicate  than  a  like  procedure  on 
older  persons,  and  that  no  one  is  justified  in  doing  it  who 
has  not  had  considerable  experience  in  adult  cases.  Further- 
more, it  should  be  noted  that  Keegan's  mortality  by  this 
operation  has  been  4.3  per  cent.,  while  Gross's  mortality 
from  lateral  lithotomy  on  children  was  2.67  per  cent. 

Special  points  of  litholapaxy  on  male  children  are  as  fol- 
lows :  use  well-fenestrated  lithotrites  ;  have  a  stylet  to  punch 
out  the  fragments  blocking  the  evacuator ;  and  crush  the 
stone  to  a  fine  mass.  There  can  usually  be  employed  a  No. 
8  lithotrite  and  a  No.  8  evacuating-tube. 

Operation  for  Stone  in  "Women. — If  the  stone  be  small 
give  the  patient  ether,  place  her  in  the   lithotomy  position^ 


MODERN  SURGERY. 

■dilate  the  urethra  with  a  uterine  dilator  until  it  admits  the 
index  finger,  and  remove  the  stone  with  the  finger,  the 
scoop,  or  the  forceps.  If  the  stone  is  found  to  be  too 
large  to  pass,  crush  it  with  a  lithotrite  and  get  rid  of  the 
debris  by  the  evacuator.  Large  stones  (two  ounces)  may 
require  a  suprapubic  lithotomy.  Vaginal  lithotomy  is  never 
required.  If  done  it  is  very  likely  to  leave  as  a  legacy  a 
vesicovaginal  fistula.  In  female  children  dilate  the  urethra, 
crush  the  stone,  and  evacuate. 

Cystotomy. — This  term  means  the  opening  of  the  bladder, 
and  it  is  usually  applied  to  an  opening  made  for  drainage, 
for  diagnosis,  for  the  removal  of  stones  and  tumors,  and  for 
the  treatment  of  ulcers.  This  opening  may  be  done  by  (i) 
a  suprapubic  cut  (as  in  suprapubic  lithotomy),  (2)  a  lateral 
perineal  cut  (as  in  lateral  lithotomy),  or  (3)  a  median  perineal 
cut  (as  in  median  lithotomy). 

Suprapubic  Cystotomy. — The  operation  is  employed  to 
allow  the  surgeon  to  explore  the  bladder,  to  treat  an  ulcer, 
or  to  provide  drainage,  or  to  remove  a  tumor.  If  the  oper- 
ation is  for  calculi,  it  is  known  as  suprapubic  lithotomy 
(page  800).  After  the  bladder  is  opened  its  interior  can  be 
illuminated  by  the  rays  of  an  electric  lamp,  which  appliance 
is  fastened  with  a  mirror  to  the  forehead  of  the  operator. 
The  operation  is  described  on  page  801.  If  an  ulcer  is  found, 
it  is  scraped  with  a  curet  or  a  spoon.  Most  cases  of  tumor 
require  suprapubic  cystotomy.  It  is  true  that  a  small  single 
growth  at  the  vesical  neck  is  accessible  by  median  cyst- 
otomy, but  the  area  for  manipulation  is  very  narrow  and  the 
growth  cannot  be  seen.  Every  large  growth,  all  cases  of 
multiple  tumors,  and  all  cases  of  tumor  with  great  depth  of 
perineum  or  with  enlarged  prostate  require  suprapubic  cyst- 
otomy, an  operation  which  allows  one  to  feel  and  to  see 
the  growth,  which  gives  room  for  manipulation,  and  which 
permits  thorough  exploration  of  the  entire  bladder.  The 
patient  is  put  in  the  Trendelenburg  position  if  water  dis- 
tention is  used,  but  is  placed  horizontally  if  air  distention 
is  employed.  After  opening  the  bladder  as  for  stone 
(page  800)  hold  the  edges  of  the  incision  apart  by  a  speculum 
(speculum  of  Keen  or  Watson)  or  by  retractors  and  throw 
in  the  electric  rays.  Growths  when  seen  can  be  twisted 
off,  a  pair  of  forceps  holding  the  base  and  another  pair 
being  used  to  twist.  Broad  growths  are  transfixed,  li- 
gated,  and  severed.  Some  growths  (as  cancer)  are  removed 
piece  by  piece  with  Thompson's  forceps,  the  base  being 
scraped.      Soft  growths  are   scraped    away  with  a  curet,  a 


DISEASES   OF  GENITO-CRINARY  ORGANS. 


809 


spoon,  or  a  finger-nail.     If  bleeding  is  severe,  check  it  by 
pressure,  by  iced  water,  or  even  by  the  actual  cautery. 

JMcdian  Cystotomy. — The  same  incision  is  made  in  the 
perineal  raphe  in  median  cystotomy  as  for  median  lithot- 
omy. A  grooved  staff  is  introduced  and  is  hooked  up 
under  the  pubes  ;  an  incision  is  made  into  the  membranous 
urethra  and  is  extended  backward  for  three-quarters  of  an 
inch,  and  a  finger  is  carried  into  the  bladder.     If  searching 


Fjg.  298. — Thompson's  ve<iical  forceps  for  removing  growths  in  the  bladder  :  for  growths 
close  to  the  neck  of  the  bladder,  with  separation  of  the  blades,  to  avoid  nipping  the  neck 
of  the  bladder. 


for  a  growth,  find  it  with  the  finger,  catch  it  with  Thompson's 
forceps,  and  twist  it  off.  Soft  growths  can  be  scraped  away. 
Stop  bleeding  by  digital  pressure  or  by  injections  of  iced 
water.  If  median  cystotomy  does  not  allow  access  to  the 
tumor,  perform  suprapubic  cystotomy. 

Growths  in  the  Female  Bladder. — Dilate  the  urethra  as 
in  a  case  of  stone,  and  scrape,  twist,  pull,  or  ligate  the 
growth  away.  If  the  growth  is  large  or  if  there  are  multiple 
growths,  perform  suprapubic  cystotomy. 


8lO  MODERN  SURGERY. 

Diseases  and  Injuries  of  the  Urethra,  Penis,  Testicles^ 
Prostate,  Seminal  Vesicles,  Spermatic  Cord,  and 
Tunica  Vaginalis. 

Injuries  may  arise  from  traumatism  to  the  perineum  or 
the  penis,  from  cuts  and  twists  of  the  penis,  from  the  pop- 
ular "  breaking  "  of  a  chordee,  from  tying  strings  around  the 
organ,  from  forcing  rings  over  it,  from  the  passage  of  instru- 
ments, or  from  the  impaction  of  calculi.  Violence  inflicted 
upon  an  erect  penis  may  fracture  the  corpora  cavernosa.  The 
writer  saw  one  man  with  a  glass  rod  broken  off  in  the  canal, 
he  having  been  in  the  habit  of  introducing  it  at  the  dictate  of 
morbid  sexual  excitement.  A  patient  in  the  Insane  Depart- 
ment of  the  Philadelphia  Hospital  had  a  ring  around  his 
penis,  which  organ  was  lacerated  into  the  urethra.  These 
injuries  are  treated  on  general  principles. 

Perineal  Bruises. — If  the  perineum  be  bruised  without 
rupture  of  the  urethra,  the  perineum  and  scrotum  swell  and 
become  discolored;  water  is  passed  with  difficulty  because  the 
extravasated  mass  of  blood  in  the  peri-urethral  tissues  oc- 
cludes more  or  less  the  canal ;  the  water  is  not  bloody ;  and 
there  are  pain  and  profound  shock.  Some  authors  desig- 
nate as  rupture  those  cases  in  which  laceration  of  the 
spongy  tissue  occurs,  without  involvement  of  the  mucous 
membrane  or  of  the  fibrous  coat,  but  they  are  properly 
contusions. 

Treatment. — Place  the  patient  in  bed  and  establish  reac- 
tion, and  when  reaction  is  complete  employ  opiates  for  the 
relief  of  pain.  Place  lint,  wet  and  kept  wet  with  lead-water 
and  laudanum,  upon  the  perineum,  alternating  every  two 
hours  with  a  fifteen-minute  application  of  the  ice-bag.  If, 
notwithstanding  these  measures,  swelling  continues,  intro- 
duce a  silver  catheter  (No.  12  E.),  tie  it  in,  and  make  firm 
pressure  upon  the  perineum  by  a  firmly-applied  T-bandage 
or  by  a  crutch  braced  against  the  thighs  or  the  foot-board  of 
the  bed.  Even  when  swelling  is  slight  retention  may  occur 
from  projection  of  a  submucous  blood-clot  into  the  canal  of 
the  urethra.  Punctured  wounds  of  the  urethra  require  ordinary 
dressings.  Incised  wounds  of  the  urethra,  when  longitudinal, 
are  closed  by  suture.  Healing  is  rapid,  and  ill  consequences 
are  not  to  be  feared.  Stricture  does  not  follow.  When  the 
wound  is  transverse,  introduce  a  catheter,  suture  the  wound 
over  the  instrument,  and  remove  the  catheter  at  the  end  of 
the  third  day.  If  a  catheter  cannot  be  introduced,  employ 
sutures,  but  at  the  first  evidence  of  extravasation  open  the 


DISEASES   OF  GENITO-URINARY  ORGANS.  8ll 

wound,  and  if  drainage  is  not  free  perform  an  external 
perineal   urethrotomy. 

Rupture  of  the  Urethra. — By  this  term  is  meant  a  lac- 
erated or  a  contused  wound  of  the  urethra,  destroying  par- 
tially or  entirely  the  integrity  of  the  canal.  A  lacerated 
wound  may  be  induced  by  fracture  of  the  cavernous  bodies 
during  erection,  the  symptoms  being  severe  hemorrhage,  in- 
tense pain,  retention  of  urine,  and  inability  to  pass  an  instru- 
ment ;  infiltration  of  urine  occurs,  and  gangrene  is  a  common 
result.  The  writer  has  seen  one  case  of  rupture  of  the  penile 
urethra  due  to  a  man's  slipping  while  shaving,  the  penis 
being  caught  in  a  partially  open  drawer,  the  drawer  being 
shut  by  his  body  coming  against  it.  Rupture,  however,  is 
almost  invariably  located  in  the  perineum,  and  it  arises  when 
the  urethra  is  suddenly  and  forcibly  pressed  against  the  arch 
of  the  pubes  by  a  blow,  by  a  kick,  or  by  falling  astride  a 
beam  or  a  fence-rail.  The  lesion  of  urethral  rupture  consists 
in  some  cases  of  laceration  of  the  spongy  tissue  and  the  mu- 
cous membrane,  a  cavity  being  formed  which  communicates 
with  the  canal,  and  which  fills  with  urine  during  micturition. 
In  other  cases  not  only  the  spongy  tissue  and  the  urethral 
mucous  membrane  are  rent  asunder,  but  the  fibrous  coat  is 
also  torn,  the  canal  opening  directly  into  the  perineal  tissues, 
among  which  a  huge  cavity  forms,  that  fills  with  blood  and 
later  with  clot,  urine,  and  pus.  The  urethra  may  be  torn 
entirely  across,  but  in  most  cases  a  small  portion  at  least  of 
its  circumference  is  uninjured.  Rupture  never  occurs  pri- 
marily and  alone  in  the  prostatic  urethra ;  it  is  extremely  rare 
in  the  membranous  urethra  unless  due  to  pelvic  fracture  ;  and 
it  is  very  unusual  in  the  penile  urethra.  The  seat  of  rupture 
in  the  great  majority  of  cases  is  in  the  region  of  the  bulb. 
Very  rarely  is  the  skin  broken. 

Symptoms. — The  symptoms  of  rupture  of  the  urethra 
are  considerable  pain,  aggravated  by  motion,  pressure,  and 
attempts  to  pass  water ;  great  shock ;  in  some  cases  mic- 
turition is  still  possible,  blood  preceding  and  discoloring  the 
stream,  for  some  blood  usually  runs  into  the  bladder ;  reten- 
tion soon  comes  on  ;  in  a  vast  majority  of  the  cases  retention 
is  absolute  from  the  very  first,  and  it  is  due  to  the  interruption 
in  the  integrity  of  the  canal  and  to  the  occlusion  of  the  chan- 
nel by  blood-clots.  Bleeding,  which  is  usually  free,  lasts  for 
several  hours,  some  little  blood  generally  appearing  externally 
and  much  being  retained  in  the  perineum,  inducing  progress- 
ive swelling.  The  presence  of  a  large  swelling  is  regarded  as 
evidence  of  urethral  rupture.     The  blood  which  is  effused  in 


8  12  MODERN  SURGERY. 

the  perineum  may  extend  under  the  fascia  to  the  penis  and 
scrotum ;  the  swelling  soon  becomes  reddish,  purple,  or  even 
black,  and  pressure  upon  it  is  apt  to  cause  blood  to  run  from 
the  meatus.  This  swelling  enlarges  when  attempts  are  made 
to  urinate.  After  a  time,  if  the  surgeon  does  not  act,  the 
urine  fills  the  perineal  cavity  and  widely  infiltrates,  and  there 
ensue  gangrene,  sloughing,  and  sepsis,  life  being  endangered 
or  fistulae  being  left  as  legacies.  In  rupture  of  the  urethra 
the  course  of  the  extravasated  urine  will  often  enable  one  to 
locate  the  seat  of  injury.  In  rupture  of  the  membranous  ure- 
thra, if  uncomplicated,  the  urine  remains  between  the  two 
layers  of  the  triangular  ligament  until  a  channel  is  opened  for 
it  by  sloughing  or  by  the  knife.  When  extravasation  occurs 
behind  the  posterior  layer  of  the  ligament  the  urine  finds 
its  way  to  the  perineum  in  the  neighborhood  of  the  anus. 
When  the  rupture  is  in  front  of  the  anterior  layer  the  urine, 
directed  by  the  deep  layer  of  the  superficial  fascia,  finds  its 
way  into  the  scrotum  and  up  on  the  belly,  but  does  not  pass 
into  the  thighs.  A  contusion  is  distinguished  from  a  rupture 
by  the  facts  that  in  the  former  the  perineal  swelling  is  not 
very  extensive  and  does  not  enlarge  on  attempting  mictu- 
rition, while  in  the  latter  it  is  extensive  and  does  enlarge 
on  attempting  to  pass  water.  Furthermore,  contusion 
does  not  cause  urethral  hemorrhage,  while  rupture  does. 
A  contusion  sometimes,  but  not  often,  prevents  the  pas- 
sage of  a  catheter;  a  rupture  almost  always,  but  not  in- 
variably, does  so.  The  mortality  from  severe  rupture  with 
extravasation  is  about  14  per  cent.  (Kaufman). 

Treatment. — In  some  cases  it  is  possible  to  suture  the 
urethra,  and  this  procedure  should  be  carried  out  when  pos- 
sible. In  order  to  suture  perform  suprapubic  cystotomy  and 
make  a  perineal  section.  Find  the  posterior  end  of  the  rupt- 
ured urethra  by  passing  a  catheter  from  the  bladder  into  the 
urethra.  Suture  with  silk.  The  sutures  pass  through  all  of  the 
coats  of  the  urethra.  The  roof  of  the  canal  is  sutured  first,  then 
a  steel  sound  is  introduced  from  the  meatus,  and  the  urethra 
is  sutured  around  the  instrument.  The  sound  is  withdrawn 
and  the  bladder  is  drained  by  Cathcart's  siphon  as  modified 
by  Keen.^  In  recent  cases  of  ruptured  urethra  the  usual  treat- 
ment is  as  follows :  immediate  perineal  section  with  turning  out 
of  the  clot ;  trimming  off  of  lacerated  edges ;  finding  the  prox- 
imal end  of  the  urethra,  passing  a  catheter  from  the  meatus 
into  the  bladder,  and  leaving  it  in  situ  until  healing  has  begun 
around  it.    In  cases  of  stricture  it  is  a  good  plan  to  excise  the 

1  See  Weir's  report  in  Med.  Record,  May  9,  1896. 


DISEASES   OF  GENITO-URINARY  ORGANS.  813 

cicatricial  tissue.  In  cases  with  extravasation  lay  open  freely 
all  pockets  of  urine  and  proceed  as  above.  If  the  proximal 
end  of  the  urethra  cannot  be  found,  either  open  the  bladder 
by  Cock's  method  of  perineal  section  without  a  guide,  cut- 
ting toward  the  apex  of  the  prostate  gland  and  carrying  the 
incision  forward  into  the  rent,  or  perform  a  suprapubic  cyst- 
otomy with  retrograde  catheterization;  that  is,  push  an  instru- 
ment from  the  bladder  into  the  wound,  and  use  it  to  guide 
a  catheter  passed  from  the  meatus  into  the  bladder.  The 
wound  is  packed  with  iodoform  gauze,  and  the  bowels  are 
tied  up  with  opium  for  a  few  days.  Many  surgeons  strongly 
disapprove  of  the  custom  of  retaining  the  catheter,  believing 
that  the  instrument  does  no  real  good,  as  urine  is  certain  to 
get  between  the  catheter  and  the  walls  of  the  urethra.  In  fact, 
it  is  quite  enough  to  stuff  the  wound  with  gauze,  the  patient 
urinating  through  the  wound  for  the  first  few  days,  after 
which  time  a  catheter  is  used.  Whatever  method  is  em- 
ployed, healing  will  require  from  six  to  eight  weeks,  and 
the  patient  must  during  the  rest  of  his  life,  from  time  to 
time,  introduce  large-sized  bougies. 

Foreign  Bodies  in  the  Urethra. — These  bodies  may 
be  calculi,  bodies  introduced  by  injury,  as  shot,  bone,  etc., 
bodies  entering  from  a  fistulous  opening  into  the  rectum,  or 
bodies  introduced  from  the  meatus,  as  broken  bits  of  cathe- 
ters, straws,  pins,  etc.  The  symptoms  vary  with  the  size 
and  the  nature  of  the  body.  Sometimes  there  are  almost  no 
symptoms  ;  at  other  times  there  are  found  great  pain,  reten- 
tion of  urine,  and  hemorrhage.  Examination  is  made  by  feel- 
ing carefully  with  a  finger  in  the  rectum  and  by  searching 
very  gently  with  a  sound,  taking  care  not  to  push  the  body 
back.  If  the  bladder  is  well  filled  with  water  when  the  body 
becomes  impacted,  inject  a  little  oil  into  the  meatus,  close 
the  lips  with  the  fingers,  and  direct  the  patient  to  forcibly 
attempt  urination,  the  surgeon  opening  the  meatus  when  the 
urethra  is  widely  distended,  the  foreign  body  being  often 
forced  out.  If  this  maneuver  fails,  and  the  foreign  body 
is  impacted  in  the  pendulous  urethra,  prevent  its  backward 
passage  by  at  once  tying  a  rubber  tube  around  the  penis. 
Try  to  squeeze  the  body  out,  and,  if  unsuccessful,  endeavor 
to  catch  it  with  a  wire  loop,  with  a  scoop,  or  with  the  long 
urethral  forceps.  If  these  methods  fail,  cut  down  upon  the 
body  and  remove  it,  dividing  any  existing  stricture.  If  a 
hairpin  is  in  the  canal,  the  feet  of  the  pin  are  almost  always 
pointing  to  the  meatus  ;  to  prevent  them  catching  on  at- 
tempted withdrawal,  the  penis  must  be  squeezed  to  approxi- 


8 14  MODERN  SURGERY. 

mate  the  feet,  and  when  they  are  adjacent  a  part  of  a  silver 
catheter  is  slipped  over  to  retain  them  in  this  position,  when 
the  pin  can  be  extracted.  If  this  fails,  drag  the  penis  against 
the  belly,  by  rectal  touch  force  the  sharp  ends  out  through 
the  integument,  cut  one  end  off,  and  then  withdraw  the  other. 
An  ordinary  large-headed  pin  is  forced  out  in  the  same  way, 
and  when  the  head  is  turned  externally  it  is  extracted  from 
the  meatus.  If  a  lithotrite  loaded  with  fragments  be  caught 
in  the  urethra,  the  surgeon  must  perform  a  perineal  section, 
clean  and  close  the  blades,  and  withdraw  the  instrument. 

Urethritis,  or  Inflammation  of  the  Urethra. — Ure- 
thral inflammations  can  be  divided  into  two  classes:  (i) 
simple,  in  which  infection  is  due  alone  to  pyogenic  cocci, 
and  (2)  specific,  in  which  the  gonococcus  is  present. 

Simple  urethritis  may  be  due  to  several  causes,  such  as 
traumatism;  great  acidity  of  the  urine;  chancer  in  the  ure- 
thra ;  contact  with  menstrual  fluid,  leukorrheal  discharge, 
the  discharge  from  malignant  disease  of  the  uterus,  ordinary 
pus,  or  acid  vaginal  discharge ;  the  passage  of  instruments ; 
irritant  diuretics ;  strong  injections ;  worms  in  the  rectum ; 
venereal  excess  and  masturbation  ;  and  the  passage  or  im- 
paction of  foreign  bodies.  A  temporary  and  mild  urethritis 
sometimes  accompanies  early  syphilitic  eruptions.  Simple 
urethritis  is  less  severe  and  prolonged  than  gonorrheal  ure- 
thritis, though  clinically  in  the  early  stage  the  surgeon  can- 
not invariably  distinguish  between  the  two  forms.  The  gono- 
coccus is  never  found  in  the  discharge  of  simple  urethritis. 
In  the  non-specific  inflammation  pus  is  not  always  present, 
many  cases  stopping  short  of  pus-formation  after  a  varying 
period  of  catarrh,  but  any  catarrh  may  become  purulent. 
A  simple  urethritis  may  be  caused  or  may  be  prolonged  for 
an  indefinite  period  by  the  presence  of  large  amounts  of 
oxalate  in  the  urine  or  the  existence  of  the  uric  acid 
diathesis  (see  Gouty  Urethritis). 

Treatment. — Seek  for  the  cause  and  remove  it.  Correct 
any  abnormal  condition  of  the  urine  by  means  of  suitable 
diet,  drugs,  and  mode  of  life.  Mild  astringent  injections  are 
useful.  It  may  be  necessary  to  flush  out  the  urethra  re- 
peatedly with  a  solution  of  silver  nitrate  (i  :  8000). 

Traumatic  Urethritis. — The  pain  in  traumatic  urethritis 
is  coincident  with  the  introduction  of  the  foreign  body.  The 
discharge,  which  may  be  bloody,  mucous,  mucopurulent,  or 
purulent,  comes  on  within  twenty-four  hours. 

Treatment. — If  the  inflammation  is  slight,  prescribe  diluent 
drinks,  paregoric,  and  a  saline.     If  severe,  put  the  patient  to 


DISEASES   OE  GEXITO-L'A'/XARY  OUGAXS.  815 

bed,  apply  hot  fomentations  to  the  perineum,  give  diluent 
drinks,  employ  suppositories  of  opium  and  belladonna,  and 
watch  for  fever  and  other  complications. 

Gouty  Urethritis. — This  condition  first  manifests  itself  in 
the  posterior  urethra,  not  in  the  anterior,  as  does  clap.  Its 
symptoms  are  great  vesical  irritabilit)' ;  pain  on  urina- 
tion ;  discharge,  usually  scanty,  associated  with  uric  acid  in 
the  urine  or  other  symptoms  of  gout.  The  treatment  com- 
prises dieting  and  the  usual  remedies  for  gout.  Purgatives 
are  given  freely,  and  full  doses  of  colchicum,  piperazin,  uro- 
tropin,  or  the  alkalies ;  hot  baths,  low  diet,  diluent  drinks, 
and  diaphoretics  are  indicated.  A  chronic  discharge  from 
the  prostatic  region  is  apt  to  linger ;  for  this  there  is  nothing 
better  than  the  usual  gouty  remedies  and  saline  waters  with 
copaiba,  cubebs,  or  sandalwood  oil.  In  many  cases  it  is 
necessar}'  to  flush  out  the  urethra  once  a  day  with  a  solu- 
tion of  silver  nitrate  (i  :  8000). 

Eczematous  Urethritis. — Berkeley  Hill  states  that  this 
disease  is  very  obstinate,  is  probably  associated  with  gout, 
and  is  met  with  in  adults  of  full  habit  or  who  are  beer- 
drinkers  and  who  have  eczema  of  the  surface  of  the  body. 
He  states  also  that  the  glans  penis  near  the  meatus  is  red 
and  tender,  and  that  the  interior  of  the  urethra  is  in  the 
same  condition.  Pain  is  constant,  and  it  is  aggravated  on 
micturition.  The  discharge  is  scanty.  The  treatment  com- 
prises injections  of  cold  water  or  irrigation  with  iced  water, 
and  internally  the  administration  of  arsenic  with  the  alkalies. 

Tuberciilar  urethritis  is  due  to  a  tubercular  ulcer,  which 
is  most  apt  to  be  seated  near  the  vesical  neck.  There  is  a 
little  pain  on  micturition,  but  there  is  intense  pain  at  one 
spot  on  passing  a  bougie.  The  discharge  is  slight  and  at 
times  bloody.  The  bladder  is  xnxy  irritable,  and  severe 
cystitis  arises  and  persists.  The  treatment  includes  fresh 
air,  sunlight,  warmth,  good  food,  and  cod-liver  oil.  The 
bladder  is  washed  out  once  a  day  with  boric-acid  solution, 
but  after  a  time  the  surgeon  will  be  forced  to  drain  by  peri- 
neal or  suprapubic  cystotomy. 

Gonorrhea  ( Clap  ;  Specific  Urethritis  ;  Tripper  ; 
Venereal  Catarrh). — Gonorrhea  is  an  acute  inflammation 
of  the  genital  mucous  membrane,  of  venereal  origin,  due  to 
the  deposition  and  multiplication  of  gonococci  in  the  cells 
of  the  membrane  and  a  mixed  infection  with  the  cocci  of 
suppuration.  In  the  male,  clap  begins  within  the  meatus 
and  fossa  navicularis  and  extends  backward  throughout  the 
lensrth  of  the  urethra.     The  mucous  membrane  swells  and 


8l6  MODERN  SURGERY. 

becomes  hyperemic,  and  there  is  a  discharge,  first  of  mucus 
and  serum,  and  then  of  pus.  In  severe  cases  the  discharge 
is  bloody  (black  gonorrhea).  For  a  week  or  more  the  in- 
flammation increases,  then  becomes  stationary  for  a  time, 
and  then  declines,  the  discharge  growing  less  profuse  and 
thinner,  a  watery  discharge  lasting  for  some  little  time. 
An  ordinary  case  of  genuine  gonorrhea  lasts  from  six  to  ten 
weeks,  and  even  a  case  limited  purely  to  the  anterior  urethra 
will  rarely  be  cured  within  four  or  five  weeks.  During  the 
acute  stage  the  entire  penis  swells  and  the  corpus  spongi- 
osum becomes  infiltrated  with  inflammatory  exudate. 

Symptoms  of  Acute  Inflammatory  Gojtorrhea. — The  period 
of  incubation  of  gonorrhea  is  from  a  few  hours  to  two 
weeks.  The  patient  notices  on  arising  a  drop  of  thin  fluid 
which  glues  together  the  lips  of  the  meatus,  and  he  feels 
some  pain  on  urination.  The  meatus  is  red  and  swollen. 
Within  forty-eight  hours  the  first  stage,  or  the  stage  of 
increase,  becomes  established.  The  meatus  is  now  red, 
swollen,  and  everted  (fish-mouth  meatus) ;  micturition  causes 
severe  pain  (ardor  urinae) ;  chordee  occurs,  especially  when 
the  patient  is  warm  in  bed.  By  chordee  we  mean  a  condition 
of  painful  erection  in  which  the  penis  is  markedly  bent.  The 
rigid  infiltration  of  the  corpus  spongiosum  prevents  it  dis- 
tending to  accommodate  itself  to  the  enlarged  corpora  caver- 
nosa, and  in  consequence  the  organ  curves.  There  is  frequent 
micturition  with  tenesmus,  and  a  profuse  discharge  which  is 
yellow,  greenish,  or  even  bloody.  The  comphcations  of  this 
stage  are  balanitis  (inflammation  of  the  mucous  membrane  of 
the  glans  penis),  balanoposthitis  (in^idivarmXion  of  the  surface  of 
the  glans  and  the  mucous  membrane  of  the  prepuce),  p/ii^/iosis 
(thickening  and  contraction  of  the  foreskin  so  that  the  glans 
cannot  be  uncovered),  and  paraphimosis  (catching  and  fixa- 
tion of  the  retracted  prepuce  behind  the  corona  glandis). 
In  the  second  or  stationary  stage,  which  lasts  from  the  end 
of  the  first  week  to  the  end  of  the  second,  the  acute  symp- 
toms of  the  first  stage  continue.  The  complications  of 
this  stage  are  peri-urethral  abscess,  lymphangitis,  solitary 
and  painful  bubo  of  the  groin  which  may  suppurate,  inflam- 
mation of  Cowper's  glands,  inflammation  of  the  prostate  or 
of  the  bladder,  and  gonorrheal  ophthalmia.  In  the  third  or 
subsiding  stage  the  symptoms  gradually  abate,  the  discharge 
becoming  scantier  and  thinner,  and  finally  drying  up.  This 
stage  is  of  uncertain  duration,  and  in  it  there  may  occur 
epididymitis,  or  inflammation  of  the  epididymis.  Among 
other  possible  complications  we  may  mention  gonorrheal 


DISEASES   OF  GENITOURINARY  ORGANS.  817 

arthritis  (page  423),  infective  endocarditis,  tenosynovitis, 
pyelitis,  perichondritis,  and  peritonitis.  Every  urethral  dis- 
charge should  be  examined  for  gonococci  in  order  to 
make  a  positive  diagnosis.  This  examination  is  made  sev- 
eral times  during  the  progress  of  the  case,  so  as  to  deter- 
mine when  the  organisms  disappear.  The  examination 
can  be  easily  made.  Place  a  drop  of  discharge  upon  a 
cover-glass,  lay  another  cover-glass  over  this,  and  slide  the 
glasses  apart.  Dry  the  slides  in  the  flame  of  an  alcohol 
lamp.  Bring  the  cover-glasses  in  contact  with  a  saturated 
solution  of  methyl-blue  in  5  per  cent,  carbolic-acid  water. 
The  staining-material  is  allowed  to  remain  in  contact  with 
the  slides  for  five  or  ten  minutes,  the  glasses  are  .washed 
with  water,  placed  in  a  solution  of  5  drops  of  acetic  acid  to 
20  c.c.  of  water,  and  kept  there  "  long  enough  to  count  one, 
two,  three  slowly,"  and  again  washed  with  water.  Exami- 
nation with  the  microscope  shows  the  gonococci  stained 
blue.i 

Subacute  or  catarrhal  gonorrhea  develops  in  men  who 
have  previously  had  gonorrhea,  as  a  result  of  prolonged  or 
repeated  coition  or  of  contact  with  menstrual  fluid  or  leukor- 
rheal  discharge.  There  is  profuse  mucopurulent  discharge, 
ver>'  little  pain  on  micturition,  rarely  chordee  or  marked 
irritability  of  the  bladder. 

Irritative  or  Abortive  Gonorrhea. —  In  this  disease  the 
symptoms,  which  are  identical  with  those  of  beginning  clap, 
do  not  increase,  but  are  apt  to  disappear  within  ten  days. 

Chronic  Urethral  Discharges. — Chronic  Urethral 
Catarrh,  which  may  follow  gonorrhea,  is  characterized  by 
the  occasional  presence  of  a  drop  of  clear,  tenacious  liquid. 
This  discharge  becomes  more  profuse  as  a  result  of  sexual 
excitement  or  the  abuse  of  alcohol. 

The  persistence  of  a  small  amount  of  milky  discharge, 
because  of  localization  of  inflammation  in  one  spot  or  the 
production  of  a  granular  patch  or  a  superficial  ulcer,  charac- 
terizes chronic  gonorrhea.  There  is  some  scalding  on  urina- 
tion ;  erections  produce  aching  pain  ;  there  are  pain  in  the 
back  and  redness  and  swelling  of  the  meatus.  All  the  symp- 
toms are  intensified  by  sexual  excitement,  by  coitus,  by 
violent  exercise,  or  by  alcoholic  excess. 

Gleet. — If  a  chronic  urethritis  lasts  over  ten  weeks  it  is 
called  gleet.  In  gleet  the  lips  of  the  meatus  are  stuck  together 
in   the  morning,  and   squeezing   them  discloses   a   drop  of 

'  Schutz's  method,  as  set  forth  by  R.  \V.  Taylor  in  his  work  upon   Venereal 
Diseases. 

52 


8l8  MODERN  SURGERY. 

opalescent  mucopurulent  fluid.  During  the  day  the  dis- 
charge is  rarely  found.  There  are  frequency  of  micturition, 
pains  in  the  back,  and  dribbling  of  urine,  and  a  bougie  will 
usually  find  a  stricture  of  large  caliber.  A  discharge  may  be 
maintained  by  chronic  prostatitis.  In  this  condition  there  are 
frequency  of  micturition  ;  a  sense  of  weight  or  dull  pain  in  the 
perineum  ;  diminished  projectile  force  of  the  stream  of  urine ; 
there  is  often  a  tendency  to  sexual  excitement  and  premature 
emission.  In  chronic  anterior  urethritis  there  is  a  discharge 
from  the  meatus  or  sticking  together  of  the  lips  in  the  morn- 
ing. In  chronic  posterior  urethritis  there  is  no  discharge  of 
pus  from  the  meatus.  If  two  beaker  glasses  are  placed  upon 
a  stand  and  the  patient  is  directed  to  urinate  first  in  one 
and  then  in  the  other,  if  he  suffer  from  chronic  anterior 
urethritis,  only  the  first  portion  will  be  cloudy  and  show 
shreds  ;  if  he  suffers  from  posterior  urethritis  of  not  very 
long  standing,  both  portions  will  be  a  little  clouded,  the  first 
with  clap  shreds,  the  second  with  hook-shaped  shreds.  In 
a  very  chronic  case  neither  sample  will  be  cloudy,  but  the 
first  portion  will  contain  shreds. 

Treatment  of  Acute  Gonorrhea.  —  Abortive  treatment 
should  be  tried  if  the  case  is  seen  early.  The  writer  formerly 
believed  that  by  cleansing  the  urethra  several  times  a  day 
with  peroxid  of  hydrogen,  following  the  hydrogen  by  the 
injection  of  oil  of  cinnamon  and  benzoinol,  many  cases  of 
gonorrhea  could  be  quickly  aborted.  Further  observations 
confirmed  by  bacterial  investigation  have  shown  that  he  was 
in  error.  True  gonorrhea  cannot  be  aborted  by  the  above- 
mentioned  plan.  Other  abortive  methods  are  the  use  of  hot 
retro-injections  of  corrosive-sublimate  solution  (1:20,000), 
two  pints  being  run  through  the  urethra  once  a  day ;  strong 
injections  of  nitrate  of  silver  or  of  tannin ;  scraping  the 
meatus  or  the  urethra  adjacent  with  cotton,  and  injecting  15 
drops  of  a  3  per  cent,  solution  of  nitrate  of  silver.  If  in 
seventy-two  hours  the  symptoms  are  not  greatly  improved, 
abortive  treatment  should  be  abandoned.  Recent  studies 
render  it  almost  certain  that  there  is  no  real  abortive  treat- 
ment. Abortive  treatment,  to  be  efficient,  would  have  to  be 
carried  out  before  the  gonococci  penetrated  the  epithelial 
cells ;  in  other  words,  would  need  to  be  instituted  before  the 
symptoms  of  the  disease  appear.  Janet  says  that  we  must 
alter  our  conception  as  to  what  constitutes  abortive  treatment, 
and  he  doubts  if  a  case  of  true  gonorrhea  was  ever  really 
aborted.^    The  method  of  irrigation  with  solutions  of  perman- 

1  Ann.  d.  Dial.  d.  org.  gen.-urin.,  1896,  p.  1031. 


DISEASES   OF  GENITO-URINARY  ORGANS.  819 

ganate  of  potassium  is  really  a  prophylactic  treatment.  Janet 
applies  his  treatment  as  evidences  of  trouble  present  them- 
selves, and  before  acute  symptoms  appear,  and  claims  that 
in  most  persons  the  disease  can  be  arrested  in  from  eight  to 
twelve  days.  The  same  plan  of  treatment  is  useful  in  a  well- 
developed  case. 

Janet's  method  is  as  follows  :  an  irrigator  is  filled  with  a 
warm  solution  of  permanganate  of  potassium  (1  :  4000).  The 
patient  after  emptying  his  bladder  is  seated  upon  a  chair  and 
his  sacrum  rests  upon  the  extreme  front  edge  of  the  chair 
(Valentine).  The  reservoir  is  joined  to  a  glass  nozzle  by  a 
rubber  tube.  The  nozzle  is  introduced  into  the  meatus,  and 
the  fluid  is  permitted  to  run  gradually  at  first,  with  full  force 
later.  In  anterior  trouble  the  fluid  runs  out  of  the  meatus 
by  the  side  of  the  nozzle.  The  anterior  urethra  is  always 
irrigated  first,  the  reservoir  being  two  feet  above  the  chair. 

In  posterior  urethritis,  after  the  anterior  urethra  has  been 
irrigated,  the  reservoir  is  raised  from  six  to  seven  feet  above 
the  bed,  the  meatus  is  held  tight  about  the  nozzle,  and  the 
fluid  overcomes  the  force  of  the  compressor  urethrae  muscles 
and  bladder  sphincter  and  enters  the  bladder.  If  the  muscles 
do  not  quickly  relax,  continue  the  hydrostatic  pressure  for 
several  minutes,  when  relaxation  will  usually  occur ;  but  if  it 
does  not  do  so,  tell  the  patient  to  urinate  and  then  repeat  the 
irrigation  (Valentine).  When  the  bladder  is  full  the  tube  is 
withdrawn  and  the  patient  micturates.  This  procedure  is 
practised  once  or  twice  a  day  for  five  or  six  days  or  even 
longer,  and  the  strength  of  the  solution  is  gradually  increased 
up  to  I  :  1000.  It  has  been  claimed  that  after  one  or  two 
weeks  of  this  treatment  gonococci  permanently  disappear  in 
the  majority  of  cases.  Valentine  of  New  York  ^  has  con- 
structed the  following  table,  which  is  of  use  to  a  practitioner 
who  wishes  to  employ  irrigations  with  permanganate  of 
potassium  in  the  treatment  of  acute  gonorrhea : 

First  day :  two  anterior  irrigations,  i  :  2000,  i  :  4000. 

Second  day :  the  same,  1  :  3000,  i  :  4000. 

Third  day:  one  intravesical,  i  :6ooo;  one  anterior,  i  :  6000. 

Fourth  and  fifth  da)-s  :  one  intravesical,  i  :  3000. 

Sixth    and    seventh    days  :  one    intravesical,    i  :  3000    or 
1 :  2000. 

Eighth  and  ninth  days :  one  intravesical,  i  :  2000  or  i  :  1000. 

Tenth  day:  one  intravesical,  i  :  1000;  anterior  irrigation, 
I  :  5000. 
If  a  stricture  exists,  it  is  not  advisable  to  employ  this  treat- 

1  N.   Y.  Med.  Record,  June  5,  1S97. 


820  MODERN  SURGERY. 

ment.  The  author  has  had  the  best  satisfaction  from  irriga- 
tions with  fluid  containing  silver  nitrate  (i  :  12,000  to  i  :  8000). 
In  treating  a  developed  case,  order  plain,  non-stimulating  diet 
and  the  avoidance  of  alcohol,  sexual  excitement,  wet,  and 
violent  or  prolonged  exercise.  The  patient  should  sleep 
under  light  covers  and  drink  much  water  daily  (Seltzer, 
ApoUinaris,  or  ordinary  water  containing  bicarbonate  of  so- 
dium). If  the  foreskin  is  long,  the  discharge  should  be  caught 
by  placing  bits  of  absorbent  cotton  over  the  meatus  and  within 
the  prepuce.  If  the  foreskin  is  short,  cut  a  small  opening  in 
a  square  piece  of  old  linen,  slip  this  linen  over  the  glans, 
catch  it  back  of  the  corona,  and  bring  the  ends  forward  with 
the  prepuce.  If  the  glans  is  completely  naked,  pin  an  old 
stocking-foot  upon  the  undershirt  and  in  it  hang  the  penis. 
Order  a  man  to  wear  a  suspensory  bandage. 

Irritative  gonorrhea  will  subside  in  a  few  days.  The 
above  directions  should  be  applied,  and  the  anterior  urethra 
should  be  washed  out  several  times  daily  with  peroxid  of 
hydrogen,  or  irrigated  once  a  day  with  a  hot  solution  of  per- 
manganate of  potassium  (i  :  4000).  In  catarrhal  gonorrhea,  at 
once  order  injections  (i  grain  to  the  ounce  of  sulphate  of  zinc; 
or  zinci  sulphas  gr.  viij,  plumbi  acetas  gr.  xv,  water  |viij ;  or 
gr.  v  of  sulphocarbolate  of  zinc  to  .?j  of  water ;  or  White's 
prescription  of  .^j  each  of  acetate  of  zinc  and  tannic  acid,  .^iij 
of  boric  acid,  5vj  of  liq.  hydrogen,  peroxid.).  For  injecting 
use  a  blunt-pointed  hard-rubber  syringe  of  a  capacity  of  three 
drams.  Let  the  patient  sit  on  a  chair,  his  buttocks  hanging 
over  the  edge ;  throw  in  a  syringeful  and  let  it  at  once  run 
out ;  throw  in  another  syringeful  and  hold  it  in  from  three  to 
five  minutes.  In  acute  gonorrhea  order  two  capsules  three 
times  a  day,  each  capsule  containing  5  grains  of  salol,  5  grains 
of  oleoresin  of  cubebs,  10  grains  of  balsam  of  copaiba,  and  i 
grain  of  pepsin.  After  the  patient  micturates  he  should 
employ  a  mild  astringent  injection.  If  an  astringent  injection 
causes  much  pain,  use  a  sedative  injection — gij  of  boric  acid, 
gr.  viij  of  aqueous  extract  of  opium,  and  Sviij  of  liquor 
plumbi  subacetatis  dilutus.  As  the  inflammation  subsides 
increase  the  strength  of  the  injection.  A  good  plan  is  to 
order  an  eight-ounce  bottle  and  eight  half-grain  powders  of 
sulphate  of  zinc.  Direct  the  patient  to  fill  the  bottle  with 
water,  in  which  one  powder  is  dissolved ;  when  this  is  used 
dissolve  two  powders  in  a  bottleful  of  water,  and  so  pro- 
gressively increase  the  strength.  When  the  discharge  ceases 
stop  the  injections  gradually.  Whenever  a  syringeful  is 
taken  from  the  bottle  a  syringeful  of  water  is  put  into  the 


DISEASES   OF  GENITOURINARY  ORGANS.  82  1 

bottle,  and  thus  pure  water  is  soon  obtained,  at  which  point 
injection  is  discontinued. 

Argonin,  which  is  a  combination  of  albumin,  silv^er,  and  an 
alkali,  is  highly  recommended  by  some  authors  as  a  local 
remedy  for  gonorrhea  (Schaffer,  Guthiel).  A  solution  of 
this  material  is  non-irritant,  the  silver  is  not  precipitated  by 
chlorids,  and  the  agent  destroys  gonococci.  It  is  used  by 
injection  or  irrigation.  If  used  by  irrigation  employ  a  i  :  500 
solution  twice  a  day.  If  used  as  an  injection  employ  a  i  :  200 
solution  six  or  eight  times  a  day.  When  the  discharge  is 
found  free  from  gonococci  and  remains  free  for  three  days, 
stop  the  argonin  and  use  an  astringent  injection. 

Methylene-blue  internally  is  occasionally  of  service  in 
gonorrhea.  A  capsule  containing  gr.  ij  of  the  drug  is  given 
three  times  a  day.  It  turns  the  urine  greenish-blue  and  occa- 
sionally induces  strangury. 

Ardor  urines  is  relieved  by  urinating  while  the  penis  lies 
in  hot  water  and  by  administering  an  alkaline  diuretic. 
CJiordce  requires  a  bowel-movement  in  the  evening  and 
sleeping  in  a  cool  room,  under  light  covers,  and  on  a  hard 
mattress ;  bromid  is  given  several  times  daily,  and  a  con- 
siderable dose  is  given  at  night ;  it  may  be  necessary  to  use 
suppositories  of  opium  and  camphor  or  to  give  hyoscin. 
Balanitis  requires  frequent  washing  with  warm  water,  drying 
with  cotton,  and  dusting  with  borated  talc  or  with  boric  acid 
and  subnitrate  of  bismuth  (i  :  6).  Balanopostldtis  requires  lead- 
water  and  laudanum  and  injections  of  black  wash  under  the 
prepuce  until  edema  of  the  foreskin  subsides,  and  then  clean- 
liness externally  and  a  powder.  Phiuwsis  requires  soaking  the 
penis  in  hot  water,  injections  of  hot  water  beneath  the  foreskin, 
followed  by  black  wash  and  the  use  of  lead-water  and  lauda- 
num externally.  If  this  fails,  circumcision  must  be  performed. 
If  paraphimosis  occurs,  grasp  the  head  of  the  penis  with  the 
left  hand,  squeeze  the  blood  out,  and  try  to  push  the  head 
back  while  with  the  right  hand  the  penis  is  pulled  upon,  as 
if  we  intended  to  lift  the  individual  by  this  organ.  If  this  fails, 
cut  the  collar  on  the  dorsum  with  scissors.  Bi/bo  requires 
iodin,  ichthyol,  or  blue  ointment,  a  spica  bandage,  and  rest.  If 
a  bubo  suppurates,  it  must  be  opened  or  aspirated.  Acute  pros- 
tatitis and  cystitis  require  confinement  to  bed,  a  milk-diet,  the 
use  of  alkaline  diuretics,  hot  sand-bags  to  the  perineum  and 
hypogastrium,  suppositories  of  opium  and  belladonna  or  ich- 
thyol, leeching  the  perineum,  and  the  discontinuance  of  the  bal- 
sams and  injections.  Abscess  of  the  prostate  requires  instant 
opening.     In  retention  of  urine  the  patient  should  try  to  pass 


822  MODERN   SURGERY. 

the  urine  while  in  a  hot  bath ;  if  this  fails,  a  soft  catheter  is 
used.  After  reHeving  the  bladder  put  the  patient  to  bed  and 
apply  hot  sand-bags  as  for  prostatitis.  Chronic  prostatitis  re- 
quires cold  hip-baths,  cold-water  enemata,  deep  urethral  injec- 
tions, plain  diet,  avoidance  of  alcohol  and  over-exertion,  coun- 
ter-irritation of  the  perineum,  and  the  relief  of  stricture  or 
phimosis.  Great  benefit  is  occasionally  derived  from  passing 
a  soft  bougie  covered  with  blue  ointment.  In  epididymitis 
put  the  patient  to  bed,  stop  injections,  shave  the  hair  from 
the  groin  and  leech  over  the  cord,  elevate  the  testicles,  keep 
the  parts  covered  with  lint  wet  with  lead-water  and  laudanum, 
and  from  time  to  time  apply  an  ice-bag.  Give  a  cathartic,  a 
fever-mixture,  and  suitable  doses  of  bromid  of  potassium  and 
morphin.  The  application  of  20  drops  of  guaiacol  in  3j  of 
cosmolin  or  olive  oil  gives  great  relief.  When  swelHng 
lingers,  after  tenderness  subsides  strap  the  testicle  with 
adhesive  plaster.  A  lingering  case  is  benefited  by  the  inter- 
nal use  of  iodid  of  potassium  and  the  local  use  of  ichthyol. 
In  gonorrheal  ophthalmia  secure  a  watch-crystal  over  the 
unaffected  eye,  put  the  patient  in  a  darkened  room,  rub  out 
the  infected  conjunctival  sac  with  cotton  soaked  in  a  2  per 
cent,  solution  of  silver  nitrate,  wash  out  the  affected  eye  often 
with  hot  boric-acid  solution,  keep  the  pupil  dilated  with  atro- 
pin,  leech  the  temple,  give  purgatives,  and  employ  hot  mus- 
tard foot-baths.     Always  send  for  an  ophthalmologist. 

Treatment  of  Chronic  Urethral  Discharges. — Gradually 
dilate  the  urethra  with  metal  sounds.  In  chronic  gonorrhea 
try  to  locate  any  existing  granular  or  ulcerated  patch  with 
a  bulbous  bougie.  When  the  point  is  discovered  apply  to  it, 
by  a  deep  urethral  syringe,  a  few  drops  of  a  2  per  cent,  solu- 
tion of  nitrate  of  silver.  The  strength  of  the  silver  solution 
can  gradually  be  increased,  or  other  solutions  can  be  substi- 
tuted (sulphate  of  copper  or  sulphocarbolate  of  zinc).  Pass  a 
large  bougie  every  other  day.  Copious  retro-irrigation  with 
hot  solutions  of  corrosive  sublimate  (i :  20,000),  permanganate 
of  potassium  (i  :  3000),  or  nitrate  of  silver  (i  :  8000)  does  good. 
In  many  cases  an  electric  endoscope  is  an  indispensable  in- 
strument. By  means  of  it  the  surgeon  is  enabled  to  locate 
the  trouble  and  treat  it  locally.  A  common  cause  of  chron- 
icity  is  lingering  inflammation  of  glandular  structures  and 
lacunae.  These  spots  should  be  touched  through  an  endo- 
scope tube,  from  time  to  time,  with  silver  nitrate  (3  per  cent.). 
A  granular  patch  should  be  treated  in  the  same  manner.  In 
any  lingering  case  of  gonorrhea  examine  the  urine,  and  direct 
suitable  treatment    for    oxaluria,  lithemia,  or  phosphaturia, 


DISEASES   OF  GENITOURINARY  ORGANS.  823 

if  any  one  of  these  conditions  exist.  Such  morbid  states  of 
the  urine  are  occasionally  responsible  for  great  prolongation 
of  the  inflammation.  In  some  cases  a  discharge  is  kept  up  by 
inflammation  of  the  seminal  vesicles  (page  834).  When  may 
a  man  be  considered  well  of  gonococcus  infection  ?  When 
shreds  disappear  from  the  urine ;  when  an  examination  on 
three  successive  days  fails  to  find  gonococci ;  when  the  urine 
is  free  from  pus,  and  when  there  has  been  no  discharge  for 
ten  days. 

Gonorrhea  of  the  rectum  occasionally,  though  very 
rarely,  occurs.  It  may  result  from  pederasty,  or  in  a  woman 
from  a  flow  of  infectious  material  from  the  genitalia  to  the  anus. 

Gonorrhea  in  the  female  may  affect  the  vulva,  the 
vagina,  the  urethra,  or  the  uterus.  The  danger  is  the  devel- 
opment of  metritis  or  salpingitis.  The  treatment  for  V7(l- 
vitis  is  to  place  the  patient  upon  a  low  diet  and  put  her  at  rest 
with  the  pelvis  elevated ;  every  two  or  three  hours  spray  the 
parts  with  peroxid  of  hydrogen,  dry  them  with  absorbent 
cotton,  and  dust  them  with  equal  parts  of  starch  and  oxid 
of  zinc.  In  severe  cases  purge,  use  hot  baths,  apply  lead- 
water  and  laudanum  locally  or  paint  the  vulva  with  silver 
solution  (gr.  xl  to  5J),  and  leech  the  groins.  If  the  vulvo- 
vaginal gland  suppurates,  open  it.  For  vaginitis  follow  the 
same  general  directions.  Syringe  out  the  vagina  eveiy  two 
hours,  first  with  Oj  of  hot  solution  of  bicarbonate  of  sodium, 
next  with  Oj  of  hot  water,  and  finally  with  Oj  of  astringent 
solution  (a  teaspoonful  of  lead  acetate,  a  teaspoonful  of  zinc 
sulphate,  a  teaspoonful  of  alum,  or  four  teaspoonfuls  of  tannin 
to  the  pint  of  hot  water)  (White).  As  the  attack  subsides, 
use  vaginal  suppositories,  each  containing  gr.  v  of  tannic  acid. 
In  some  cases  apply  solutions  of  silver  nitrate  i  :  200,  and 
tampon  with  boroglycerid  and  ichthyol,  8  per  cent.  (Le 
Blonde).  Metritis  must  be  prevented,  and  it  is  a  wise  pre- 
caution to  apply  iodin  from  time  to  time.  For  urethritis  use 
astringent  injections  locally  and  copaiba  and  cubebs  by  the 
mouth.  In  chronic  cases  use  strong  solutions  of  silver 
nitrate.  The  urethra  and  bladder  may  be  irrigated  with  sil- 
ver nitrate  (i  :  8000).  For  uterine  gonorrlica  observe  the  same 
general  management.  Swab  out  the  uterus  with  tincture  of 
iodin ;  use  tampons  of  iodoform  gauze  and  injections  of 
peroxid  of  hydrogen. 

Stricture  of  the  urethra,  or  narrowing  of  the  urethral 
caliber,  is  divided  into  inflaviniatory ,  spasmodic,  and  organic. 
The  so-called  ijiflammatory  or  congestive  stricture  is  not  a 
stricture,  but  is  an  inflammatoiy  swelling  of  the  mucous 


824  MODERN  SURGERY. 

membrane.  Spasmodic  stricture  does  not  exist  alone,  but 
complicates  organic  stricture,  a  hyperesthetic  urethra,  or  an 
inflamed  bladder.  Organic  stricture  is  a  fibrous  narrowing 
of  the  urethra,  due,  as  a  rule,  to  chronic  gonorrheal  inflam- 
mation or  to  traumatism.  Traumatic  strictures  occur  in  the 
bulbous  or  membranous  urethra,  and  are  due  generally  to 
force  applied  to  the  perineum,  the  urethra  being  squeezed 
between  the  subpubic  ligament  and  the  vulnerating  body. 
Strictures  resulting  from  gonorrheal  inflammation  occur  in 
the  penile,  bulbous,  or  membranous  urethra.  Stricture  never 
forms  in  the  prostatic  urethra,  except  as  a  result  of  trau- 
matism. Recent  strictures  are  soft  and  are  easily  distended. 
Old  strictures  and  traumatic  strictures  are  very  dense.  A 
resilient  stricture  is  one  which  contracts  quickly  after  dilata- 
tion. The  nearer  a  stricture  is  to  the  meatus,  the  more 
fibrous  it  is.  A  congenital  stricture  is  congenital  narrow- 
ness of  a  portion  of  the  urethra,  usually  the  portion  near  the 
meatus.  The  more  fibrous  a  stricture  is,  the  more  it  narrows 
the  urethra  and  the  less  dilatable  it  is.  A  stricture  may  be 
annular  (forming  a  ring  around  the  urethra),  tubular  (sur- 
rounding the  urethra  for  a  considerable  distance),  or  bridle 
(when  a  band  crosses  the  urethra  from  wall  to  wall).  A 
stricture  of  large  caliber  will  admit  an  instrument  larger 
than  a  No.  15  French  sound.  A  stricture  of  small  caliber 
admits  an  instrument  smaller  than  a  No.  1 5  French  sound. 
An  impermeable  stricture  will  not  admit  the  passage  of  any 
instrument.  Impermeable  is  more  or  less  a  relative  term. 
A  stricture  may  be  impermeable  when  an  anesthetic  is  not 
used,  and  permeable  when  the  patient  is  anesthetized,  or  may 
be  impermeable  to  one  surgeon,  but  permeable  to  another. 
Impermeability  is  often  a  temporary  condition  due  to  inflam- 
matory edema  about  an  organic  stricture. 

Symptoms  and  Results  of  Stricture. — There  is  usually 
a  history  of  repeated  attacks  of  urethritis.  A  chronic  dis- 
charge may  exist,  the  amount  of  which  is  variable.  There 
is  a  feeling  of  weight  in  the  perineum,  soreness  of  the 
back,  hypochondriacal  fancies,  and  frequency  of  micturition. 
There  is  difficulty  in  starting  the  stream  in  micturition ; 
the  stream  is  small,  twisted,  often  forked,  and  it  dribbles  long 
after  the  conclusion  of  micturition,  so  that  the  penis  must  be 
"  milked "  before  it  is  returned  within  the  clothing.  The 
urethra  back  of  the  stricture  dilates,  a  pouch  forms,  drops 
of  urine  collect  and  decompose,  and  a  chronic  inflammation 
results  in  the  mucous  membrane  or  the  parts  adjacent,  which 
inflammation  may  go  on  to  ulceration  or  to  peri-urethral  ab- 


DISEASES   OF  GENITO-URINARY  ORGANS.  825 

scess.  A  urinary  fistula  results  from  the  opening  externally 
of  a  peri-urethral  abscess.  Retention  of  urine  may  occur, 
not  from  obliteration  of  the  tube  by  the  growth  of  the 
stricture,  but  by  edematous  swelling  in  the  neighborhood  of 
the  stricture,  due  to  cold,  wet,  venereal  excitement,  the  use 
of  alcohol,  over-exertion,  etc.  Spasm  of  the  muscles  re- 
sults, and  contact  of  the  urine  increases  the  spasm,  and  spasm 
plus  edema  of  the  mucous  membrane  closes  the  urethra. 
Spasm  may  exist  in  the  urethra  itself  and  in  the  muscles  of 
the  neck  of  the  bladder,  but  is  only  a  temporary  condition. 
In  old  strictures  the  bladder  is  hypertrophied  and  often  fas- 
ciculated, and  is  very  liable  to  cystitis.  The  diagnosis  of 
stricture  and  of  its  location  is  made  by  the  use  of  exploratory 
bougies.  In  this  examination  the  author  follows  to  a  great 
extent  the  plan  of  Ramon  Guiteras,  which  is  as  follows :  ^ 
have  the  patient  pass  urine  into  two  glasses.  Examine  the 
urine  for  clap-shreds.  Cloudiness  in  the  first  glass  shows  that 
urethral  discharge  exists.  Cloudiness  in  the  second  glass 
points  to  cystitis.  The  patient  is  placed  recumbent  with  his 
shoulders  elevated,  and  the  urethra  is  washed  out  with  warm 
salt  solution.  Bulbous  sounds  are  inserted,  beginning  with 
No.  15  French.  If  this  passes  with  ease,  take  a  larger  size 
and  note  where  strictures  are  situated  by  the  catch  on  with- 
drawal. If  No.  1 5  does  not  pass,  use  a  smaller  size.  Remember 
that  the  posterior  layer  of  the  triangular  ligament  catches  a 
bulbous  instrument  on  withdrawal.  If  the  meatus  is  too 
small  to  permit  of  exploration,  divide  it  with  a  curved  bis- 
toury, cutting  from  within  outward.  After  cutting  the  meatus 
bleeding  is  arrested  with  styptic  cotton,  and  a  piece  of  ab- 
sorbent cotton  is  tucked  into  the  cut.  After  each  act  of 
micturition  the  patient  inserts  a  fresh  bit  of  cotton,  and 
after  three  days  the  urethral  examination  is  proceeded  with. 
Treatment. — Strictures  of  large  caliber  in  the  deep  urethra 
require  gradual  dilatation.  A  steel  bougie  is  introduced  every 
third  or  fourth  day,  the  size  being  gradually  increased.  Never 
anoint  a  bougie  with  cosmolin,  as  it  may  become  a  nucleus 
for  a  stone  in  the  bladder ;  use  oil  or  glycerin.  Before  pass- 
ing an  instrument  the  patient  urinates  and  his  urethra  is 
washed  out  with  boiled  water.  The  sound  is  rendered  sterile 
by  boiling  before  using.  Gradual  dilatation  can  be  effected  by 
the  use  of  the  dilator  of  Oberlander,  the  tube  being  distended 
to  the  extent  of  three  millimeters  every  fifth  day.  If  after 
dilatation  there  is  urethral  spasm,  pain,  or  very  frequent 
micturition,  suspend   the  treatment  for  a  number   of   days 

*  ]\[ed.  Record,  Nov.  14,  1896. 


826  MODERN  SURGERY. 

and  order  each  night  a  hot  hip-bath  and  a  dose  of  paregoric. 
In  effecting  gradual  dilatation  by  sounds  the  instrument 
should  be  introduced  every  fifth  day,  and  during  the  treat- 
ment the  patient  should  not  use  alcohol,  should  refrain 
from  sexual  excitement,  should  avoid  cold  and  damp,  and 
should  take  internally  capsules  containing  boric  acid  and 
salol.  It  is  rarely  necessary  to  dilate  above  No.  32  French. 
After  the  surgeon  finishes  treatment  he  teaches  the  patient 
to  use  an  instrument  and  directs  him  to  pass  it  once  a  month. 
Strictures  in  the  pendulous  urethra,  if  soft,  are  treated  by 
gradual  dilatation ;  if  fibrous  and  contractile,  by  internal 
urethrotomy.  In  performing  internal  urethrotomy  prepare 
the  patient  carefully ;  for  several  days  before  the  operation 
give  salol  and  boric  acid  by  the  mouth,  and  wash  out  the 
bladder  repeatedly  with  boric-acid  solution.  Be  thoroughly 
aseptic.  Anesthetize  the  patient.  Before  cutting  irrigate  the 
urethra  with  warm  normal  salt  solution,  and  after  cutting 
irrigate  again  and  tie  in  a  rubber  catheter.  These  precau- 
tions will  prevent  urethral  fever.  In  cutting,  insert  Gross's 
urethrotome  (Fig.  302)  back  of  the  stricture,  spring  out  the 
blade,  cut  the  stricture  on  the  roof  of  the  urethra,  close 
the  blade,  withdraw  the  instrument,  and  pass  a  full-sized 
bougie. 

Stricture  of  the  meatus  requires  incision  with  a  knife  and 
the  use  of  a  meatus  bougie  until  healing  is  complete.  Strict- 
ures of  small  caliber  in  front  of  the  membranous  urethra  re- 
quire gradual  dilatation  and,  if  this  fails,  internal  urethrotomy 
or  divulsion.  Internal  urethrotomy  can  be  performed  with 
the  urethrotome  of  Maisonneuve  (Fig.  300).  This  instru- 
ment is  shaped  like  a  sound,  has  a  groove  upon  its  surface,, 
and  into  this  groove  a  shaft  carrying  a  triangular  knife  can 
be  inserted.  The  staff  is  screwed  to  a  guide,  the  guide  is  car- 
ried into  the  bladder,  and  the  staff  follows  it.  The  point  of 
the  staff  is  carried  to  the  prostatic  urethra  and  the  guide  curls 
up  in  the  bladder.  The  penis  is  held  upon  the  stretch,  the 
blade  is  inserted  and  pushed  down  through  the  stricture. 
This  instrument  cuts  the  stricture,  but  not  the  healthy 
ureter.  For  divulsion  the  patient  is  prepared  as  for  inter- 
nal urethrotomy.  The  divulsor  of  Gross,  or  of  Sir  Henry 
Thompson,  or  of  Gouley  (Figs.  301,  303,  304)  is  intro- 
duced, the  blades  are  separated,  the  instrument  is  with- 
drawn, a  large  bougie  is  passed,  and  a  catheter  is  tied  in 
the  bladder.  Strictures  of  small  caliber  in  the  deep  ure- 
thra require  gradual  dilatation  ;  if  this  fails,  employ  external 
urethrotomy.    In  strictures  of  the  deep  urethra,  if  only  a  fill- 


DISEASES   OE  GENirO-URINARY  ORGANS. 


827 


form  bougie  can  be  introduced,  the  bougie  can  be  left  in  ])lace 
and  in  a  day  or  two  another  can  be  .shpi)ed  in  beside  it,  until  in 
a  few  days  the  channel  is  permeable  by  a  metal  bougie.     A 


Fig.  299 — Syme's  staff. 


Fig   300. — ^laisonneiive'.s  urethrotome. 


tunnelled  catheter  can  be  sHpped  over  the  filiform  bougie, 
both  be  withdrawn,  and  a  metal  bougie  passed.  A  tun- 
nelled and  grooved  staff  can  be  carried  in  over  the  bougie 


828 


MODERN  SURGERY. 


and  external  urethrotomy  be  performed.  Thompson's  dilator 
can  be  carried  in  over  the  filiform  and  the  stricture  be  di- 
vulsed.  Fort's  method  of  electrolysis  is  of  value.  This 
surgeon  treats  stricture  by  linear  electrolysis.  His  instru- 
ment looks  like  a  whip,  and  it  has  a  platinum  blade  pro- 


t 


Fig.  301. — Gross's  urethral  dilator. 


Fig.  302. — S.  W.  Gross's  explora- 
tory urethrotome. 


jecting  from  about  the  center.  The  blade  is  connected  with 
the  negative  pole  of  a  galvanic  battery  and  the  positive  pole 
is  placed  over  the  pubes.  The  guide  carrying  the  blade  is 
inserted  into  the  urethra,  and  when  the  blade  comes  against 
the  stricture  the  current  is  turned  on  and  the  platinum  passes 


DISEASES   OF  GENITO-URINARY  ORGANS. 


829 


rapidly  through  the  constriction.  The  current  is  turned  off 
and  the  instrument  is  carried  onward  until  it  strikes  another 
stricture,  when  the  current  is  again  turned  on,  and  so  on. 
The  necessary  current-strength  is    10  to   15   ma.     The  op- 


FiG.  303. — Thompson's  divulsor. 

eration  requires  twenty  to  thirty  seconds  and  causes  but 
little  pain.  After  its  performance  a  sound  is  passed,  a  No. 
22  of  the  French  scale.  The  patient  need  not  be  confined 
to    bed    after    this   operation.       By   Fort's    method   we    act 


Fig.  304. — Gouley's  divulsor. 


purely  upon  the  diseased  tissue.  In  impassable  stricture 
of  the  deep  urethra  perform  external  perineal  urethrotomy 
without  a  guide  (the  operation  of  Cock  or  of  Wheelhouse). 
Urethral  Fever. — Any  operation  upon  the  urethra  may 
be  followed  by  a  chill  owing  to  shock  (urethral  shock),  and 
this  may  be  followed  by  a  nervous  fever.  Urethral  fever 
proper  is  a  sapremia  which  may  follow  a  urethral  opera- 
tion. This  condition  is  due  to  absorption  of  toxic  elements 
which  may  be  in  the  urine,  may  have  been  in  the  urethra,  or 
may  have  been  introduced  from  without.  It  usually  follows 
the  first  urinary  act  after  operation.  It  begins  with  a  violent 
chill  and  presents  the  characteristics  of  a  septic  fever.  It  is 
accompanied  by  a  marked  tendency  to  urinary  suppression, 
and  may  eventuate  in  septicemia  or  pyemia.  Urethral  fever 
can  be  prevented  by  rigid  antisepsis.  If  this  fever  should 
arise,  a  catheter  must  be  tied  in  the  bladder,  the  bladder  and 
urethra  must  be  repeatedly  irrigated  with  aseptic  or  anti- 
septic fluids,  and  the  patient  must  be  given  urinary  antiseptics 
and  stimulants  by  the  mouth. 


830  MODERN  SURGERY. 

Perineal  section  is  external  perineal  urethrotomy.  There 
are  three  methods,  the  operation  of  Syme,  of  Wheelhouse, 
and  of  Cock. 

Syme's  Operation.  —  This  operation  is  employed  if  a 
stricture  is  very  contractile,  if  dilatation  fails  to  cure,  or  if 
urethral  instrumentation  causes  fever.  The  patient  is  anes- 
thetized, Syme's  staff  (Fig.  299)  is  introduced,  and  the  sur- 
geon makes  an  incision  in  the  midline  of  the  perineum  and 
exposes  the  staff  just  above  the  shoulder  of  the  instrument. 
The  knife  is  carried  along  the  groove  and  divides  the  strict- 
ure. A  catheter  is  passed  into  the  bladder  from  the  meatus 
and  is  retained  for  several  days,  and  the  wound  is  dressed 
antiseptically.  After  the  catheter  is  removed  it  must  be 
used  every  six  hours  -until  the  urine  comes  entirely  by  the 
meatus.  From  time  to  time,  for  the  rest  of  the  patient's 
life,  a  full-sized  sound  should  be  passed. 

"Wheelhouse's  Operation. — This  operation  is  employed 
for  the  treatment  of  impermeable  stricture.  Wheelhouse's 
staff  is  passed  into  the  urethra  until  it  blocks  on  the  stricture. 
The  perineum  is  incised  down  to  the  staff  and  in  front  of  the 
stricture.  The  edges  of  the  cut  urethra  are  held  apart  with 
forceps,  the  surgeon  seeks  for  the  opening  through  the  strict- 
ure, passes  a  fine  probe  through  it,  divides  the  stricture,  carries 
into  the  bladder  from  the  wound  an  instrument  known  as  a 
gorget  to  dilate  the  canal  and  furnish  a  solid  floor  to  facilitate 
the  introduction  of  a  catheter.  With  the  gorget  in  place  a 
metal  catheter  is  carried  from  the  meatus  into  the  bladder. 
The  gorget  is  removed  and  the  catheter  is  tied  in  place. 
After  three  or  four  days  the  catheter  is  removed  and  is  then 
passed  frequently.  The  perineal  wound  is,  of  course,  dressed 
antiseptically. 

Cock's  Operation,  —  This  operation  opens  the  urethra 
back  of  the  stricture  and  without  a  guide.  The  surgeon 
introduces  into  the  rectum  the  index  finger  of  the  left  hand, 
and  the  tip  of  the  finger  is  rested  upon  the  apex  of  the  prostate 
gland.  The  surgeon  incises  the  median  line  of  the  perineum, 
the  back  of  the  knife  being  toward  the  anus.  When  the 
point  of  the  knife  is  felt  to  be  near  the  finger  the  handle  is 
lowered  slightly,  the  blade  is  placed  a  little  oblique,  and  the 
urethra  is  opened.  A  catheter  is  passed  into  the  bladder 
from  the  wound  and  retained. 

epispadias  is  a  congenital  cleft  in  the  corpora  cavernosa, 
the  roof  of  the  urethra  being  absent.  It  is  remedied  by  a 
plastic  operation. 

Hypospadias  is   a  congenital  cleft  on  the  floor  of  the 


DISEASES   OF  GENITOURINARY  ORGANS.  83  I 

urethra,  this  channel  being  a  gutter  instead  of  a  canal.     It  is 
remedied  by  a  plastic  operation. 

Chancroid  (soft  chancer ;  the  local  venereal  sore)  is 
a  p\'ogcnic  ulcer,  usually  of  venereal  origin.  The  name 
chancroid  was  introduced  by  Clerc,  who  believed  that  a  soft 
sore  resulted  from  inoculating  a  person  already  syphilitic 
with  the  products  of  a  hard  sore.  He  further  held  that  when 
a  soft  sore  arose  the  syphilitic  poison  lost  its  infective  prop- 
erties, and  "  could  be  transmitted  as  a  soft  sore  to  a  healthy 
person,  and  not  cause  general  infection."  ^  This  form  of  ulcer 
is  not  connected  with  the  syphilitic  poison  and  is  not  due  to 
any  special  or  chancroidal  poison,  but  is  produced  by  inflam- 
matory products  or  irritating  secretions.  In  fact,  soft  sores 
may  arise  without  a  causative  sexual  intercourse,  as  is  seen 
sometimes  in  cases  of  herpes  in  a  man  with  gonorrhea,  the 
herpetic  ulcers  becoming  chancroids.  As  a  rule,  chancroids 
are  of  venereal  origin,  and  result  from  contact  with  other 
chancroids,  pus,  mucopus,  or  areas  of  ulceration.  There  is 
no  special  germ.  A  chancroid  appears  soon  after  inter- 
course, usually  within  five  days,  always  within  ten  days.  It 
is  first  manifested  by  a  pustule  which  ruptures  and  discloses 
an  ulcer.  This  ulcer  has  sharply-defined  and  undermined 
margins ;  it  looks  "  punched  out ; "  the  base  is  gray  and 
sloughy ;  the  discharge  is  profuse,  purulent,  foul,  and  auto- 
inoculable,  and  causes  fresh  chancroids  by  flowing  over  the 
parts.  The  area  around  a  chancroid  is  red  and  inflamed,  and 
considerable  pain  is  apt  to  be  complained  of  The  original 
chancroid  spreads  and  new  sores  appear.  The  edge  of  a 
chancroid  is  not  indurated  unless  caustics  have  been  used  or 
there  is  mixed  infection  with  syphilis.  Inflammatory  indura- 
tion fades  gradually  into  the  tissues,  but  the  induration  of  a 
hard  chancre  is  sharply  defined.  When  a  chancroid  after  a 
time  displays  marked  and  sharply-outlined  induration  it 
points  to  mixed  infection  of  chancroid  and  syphilis.  Chan- 
croids are  not  followed  by  constitutional  symptoms,  but  are 
apt  to  be  accompanied  by  painful  inflammatory  buboes  w^hich 
are  prone  to  suppurate.  In  hospital  practice  about  30  per 
cent,  of  patients  develop  buboes.  The  bubo  may  be  one- 
sided or  bilateral.  If  pus  forms,  it  does  not  contain  organisms. 
The  adenitis  of  chancroid  is  due  purely  to  the  absorption  of 
toxins.  Cases  have  been  reported  in  which  non-indurated 
sores  were  followed  by  syphilis.  It  is  probable  that  a 
mixed  infection  existed,  and  that  induration  was  overlooked, 
because  a  papular  initial  lesion  w^as  underneath  the  chancroidal 

^  Syphilis,  by  Alfred  Cooper. 


832  MODERN  SURGERY. 

ulcer.  When  inflammation  in  chancroids  is  high  a  rapidly 
destructive  ulceration  known  as  phagedena  may  arise,  but 
this   process   is   far   more  common   in   syphilitic   sores. 

Treatment. — Ordinary  cases  of  chancroid  are  treated  by 
spraying  with  peroxid  of  hydrogen,  drying  with  cotton,  touch- 
ing each  sore  first  with  pure  carbolic  acid  and  then  with  pure 
nitric  acid,  and  dusting  with  iodoform  or  with  calomel.  Every 
few  hours  after  this  application  the  patient  soaks  the  penis  in 
hot  salt  water  (a  teaspoonful  of  salt  to  half  a  pint  of  water), 
sprays  the  sores  with  peroxid  of  hydrogen,  dries  with  cot- 
ton, and  dusts  with  iodoform  or  with  calomel.  As  soon  as 
granulation  begins  the  sores  should  be  dressed  with  i  part  of 
ointment  of  nitrate  of  mercury  to  7  parts  of  cosmolin.  Mild 
cases  do  well  without  cauterizing,  peroxid  of  hydrogen  being 
frequently  used  and  a  drying  powder  being  employed.  In 
chancroids  with  phimosis  slit  up  the  foreskin,  burn  the  edges 
of  the  wound  with  pure  carbolic  acid,  and  treat  the  sore 
by  cauterization.  A  set  circumcision  often  fails  because 
of  infection  of  the  stitch-holes.  Phagedena  requires  the  in- 
ternal use  of  iron,  quinin,  and  milk-punch,  and  the  local 
use  of  powerful  caustics  (bromin  or  nitric  acid  or  even  of 
the  actual  cautery).  In  some  cases  continuous  antiseptic 
irrigation  is  valuable.  When  a  bubo  first  begins  order  rest, 
apply  iodin  or  an  ointment  of  belladonna  or  ichthyol,  and 
make  pressure  by  a  spica  bandage  of  the  groin.  Some 
surgeons  advise  the  injection  of  20-40  minims  of  a  solu- 
tion of  carbolic  acid  (gr.  x  to  the  ounce),  but  we  have 
never  seen  any  benefit  from  it.  Some  inject  a  i  per  cent, 
solution  of  bichlorid  of  mercury,  but  the  proceeding 
causes  intense  pain.  Welander  recommends  the  injection 
of  a  I  per  cent,  solution  of  benzoate  of  mercury.  We 
have  had  no  experience  with  these  methods.  If  the  bubo 
persists,  even  though  it  does  not  suppurate,  it  should  be 
completely  excised.  If  pus  forms,  several  methods  of  treat- 
ment are  open  to  us.  Aspiration,  injection  with  a  solution 
of  carbolic  acid,  squeezing  out  the  acid  and  injecting  10 
per  cent,  ointment  of  iodoform  and  glycerin,  and  sealing  the 
opening  with  collodion  (Scott  Helms).  Hayden  makes  a 
puncture,  squeezes  out  the  pus,  washes  out  the  cavity  with 
peroxid  of  hydrogen  and  then  with  corrosive-sublimate 
solution,  injects  warm  iodoform  ointment,  and  dresses  with 
cold,  moist,  corrosive-sublimate  gauze  to  set  the  ointment. 
Otis,  Fontain,  Perry,  and  others  commend  this  plan.  We 
have  often  found  it  to  succeed.  If  the  above-mentioned 
plan  fails,  if  it  is  not  used,  or  if  an   ulcer  or  sinus   exists, 


DISEASES   OF  GENITO-URINAKY  ORGANS.  833 

incise,  curet,  cauterize  with  pure  carbolic  acid,  cut  away 
hopelessly  infiltrated  skin,  and  pack  the  wound  with  iodo- 
form gauze.  In  some  cases  it  will  be  necessary  to  extirpate 
fragments  of  gland. 

Phimosis  is  a  condition  of  the  prepuce  that  renders 
retraction  over  the  glans  impossible.  It  is  usually  congenital, 
but  it  may  arise  from  inflammation.  Congenital  phimosis 
causes  retention  of  sebaceous  matter,  which  decomposes  and 
lights  up  inflammation.  The  prepuce  is 
apt  to  grow  fast  to  the  glans.  Congeni- 
tal phimosis  may  induce  irritability  of  the 
bladder,  incontinence  of  urine,  prolapse 
of  the  rectum,  and  various  nervous  symp- 
toms. The  treatment  is  cirauncision.  ^ 
Asepticize  the  parts.  Grasp  the  foreskin  fig.  305.-circumcis- 
and  the  mucous  membrane  with  two  for-  ^dKoTaizigV '''"'''''' 
ceps,  draw  the  prepuce  forward,  catch  the 
skin  (at  the  point  it  is  desired  to  cut)  horizontally  between  the 
handles  of  a  pair  of  scissors,  and  cut  off  the  redundant  prepuce. 
Retrench  the  excess  of  mucous  membrane  by  cutting  around 
with  scissors  one-quarter  of  an  inch  from  the  glans,  stitch  the 
skin  to  the  mucous  membrane  with  catgut,  and  dress  with 
sterile  gauze  (Fig.  305). 

Fracture  of  the  penis,  which  is  a  laceration  of  the  caver- 
nous bodies  with  extravasation  of  blood,  occurs  occasionally 
during  coition.  The  treatment  consists  of  cold  and  bandaging^ 
to  arrest  bleeding,  and  occasionally  incisions  to  let  out  clot. 

Gangrene  of  the  penis  arises  from  phagedena,  from 
tying  constricting  bands  around  the  organ,  from  fracture 
with  excessive  hemorrhage,  and  from  paraphimosis.  If  ex- 
tensive, it  requires  amputation. 

Cancer  of  the  penis  is  commonest  in  persons  with  phi- 
mosis. In  a  limited  epithelioma  of  the  foreskin  circumcision 
is  performed  and  the  glands  of  the  groin  are  removed  ;  if  can- 
cer affects  the  glans,  amputation  is  required,  and  the  glands 
are  removed. 

Amputation  of  the  Penis. — Ricord  advised  cutting  off 
the  organ  with  a  single  stroke  of  the  knife,  making  four  slits 
in  the  mucous  membrane  of  the  urethra,  and  stitching  each 
of  these  flaps  to  the  skin.  Treves  splits  the  skin  of  the 
scrotum  along  the  raphe,  separates  the  halves  of  the  scrotum 
down  to  the  corpus  spongiosum,  passes  a  metal  catheter 
down  to  the  triangular  ligament,  inserts  a  knife  between  the 
corpus  spongiosum  and  the  corpora  cavernosa,  withdraws 
the  catheter,  cuts  the  urethra  across,  detaches  the  urethra 
53 


834  MODERN  SURGERY. 

from  the  penis  back  to  the  triangular  hgament,  cuts  around 
the  root  of  the  penis,  divides  the  suspensory  hgament, 
detaches  each  crus  from  the  pubes,  sHts  up  the  corpus  spon- 
giosum half  an  inch,  stitches  its  edges  to  the  rear  end  of  the 
scrotal  incision,  introduces  a  drainage-tube,  ligates  the  ves- 
sels, and  sutures  the  wound. 

Seminal  Vesiculitis. — Inflammation  of  the  seminal  ves- 
icles is  due  to  the  extension  of  a  gonorrheal  inflammation  or 
a  pyogenic  process. 

Acute  inflammation  is  made  evident  by  frequent  and  pain- 
ful micturition,  pains  in  the  anus,  rectum,  and  perineum,  and 
possibly  the  hip-joint,  back,  and  thigh.  Defecation  and  mic- 
turition are. excessively  painful.  Persistent  erections  may  take 
place,  and  in  some  cases  bloody  ejaculations  occur.  Rectal 
examination  detects  the  enlarged  and  tender  vesicles  external 
to  the  lateral  lobes  of  the  prostate  and  on  a  higher  level. 

Treatment. — Abandon  local  urethral  treatment  and  treat 
the  patient  as  for  acute  prostatitis. 

Chronic  vesiculitis  may  result  from  the  acute  form  or  may 
come  on  insidiously  in  an  individual  with  gonorrhea.  It  is  one 
of  the  causes  of  chronic  urethral  discharge.  The  patient  suffers 
from  imperative  and  frequent  demands  to  micturate,  and  he 
has  a  gleety  discharge  which  becomes  worse  and  better,  but 
does  not  disappear.  This  chronic  inflammation  is  beHeved 
to  persist  because  of  narrowing  of  the  duct,  and  consequent 
incomplete  drainage  of  the  vesicle. 

Treatment. — Treat  the  posterior  urethritis  by  ordinary 
methods.  Use  hot  rectal  enemata.  Milk  the  ducts  by 
Fuller's  method  once  every  seven  days.  The  patient's 
bladder  should  be  full.  He  leans  over  a  chair-back,  the 
knees  being  straight  and  the  body  at  a  right  angle  to  the 
thighs.  The  surgeon  introduces  his  finger  into  the  rectum 
and  makes  pressure  over  the  pubes  with  the  fist  of  the  other 
hand.  The  finger  comes  in  contact  with  the  lower  half  of 
the  vesicle ;  it  makes  firm  pressure  for  a  moment,  and  is  then 
drawn  slowly  toward  the  duct.  This  stroking  is  repeated 
several  times.  The  other  vesicle  is  treated  in  the  same 
manner.  This  maneuver  empties  the  vesicle  and  hastens 
the  resolution  of  inflammation.  After  the  completion  of  the 
stripping  the  patient  makes  water. 

Hypertrophy  of  the  prostate  gland  is  a  senile  change 
occurring  only  after  the  age  of  fifty,  and  being  most  apt  to 
occur  after  the  age  of  sixty.  All  the  lobes  may  be  enlarged 
equally,  all  may  be  enlarged  but  unequally,  or  only  one  lobe 
may  be  enlarged.     Prostatic  hypertrophy  causes  narrowing 


DISEASES   OF  GENITOURINARY  ORGANS.  835 

and  lengthening  of  the  urethra,  and  gives  this  tube  a  tor- 
tuous course.  The  opening  of  the  urethra  into  the  bladder 
is  pushed  to  a  higher  level,  and  there  forms  behind  it  a  pouch 
in  which  urine  collects.  This  urine,  which  is  known  as 
rcsidiial  urine,  may  collect  in  large  quantity ;  it  cannot  be 
voluntarily  expelled,  and  it  is  apt  to  decompose,  producing 
cystitis.  The  bladder  enlarges,  thickens,  and  becomes  fas- 
ciculated, micturition  becoming  very  difficult  and  sometimes 
impossible.  An  enlarged  middle  lobe  will  block  the  urine  and 
the  bladder  inevitably  becomes  greatly  distended.  In  hyper- 
trophy of  the  prostate  the  ureters,  the  renal  pelves,  and  calyces 
may  distend,  and  surgical  kidney  may  develop. 

Symptoms. — In  80  per  cent,  of  all  cases  there  is  only  slight 
inconvenience.  The  stream  of  urine  is  slow  to  start  and  falls 
feebly  from  the  end  of  the  penis.  The  last  drops  fall  entirely 
without  control,  and  there  are  occasional  episodes  of  noc- 
turnal frequency  of  micturition.  In  20  per  cent,  of  all  cases 
the  bladder  cannot  entirely  be  emptied  and  residual  urine 
collects  in  the  bladder.  Frequency  of  micturition  comes  on, 
particularly  at  night ;  the  patient  has  to  get  up  often  ;  the 
bladder  never  feels  empty ;  and  cystitis  is  apt  to  arise.  The 
urine,  at  first  acid  and  clear,  becomes  neutral  and  cloudy,  and 
finally  ammoniacal  and  turbid,  and  contains  bacteria,  muco- 
pus,  precipitates  of  phosphates,  and  blood.  Above  the  pubes 
there  is  aching  pain,  soon  spreading  to  the  perineum,  which 
pain  is  increased  when  the  bladder  is  distended  and  during 
micturition.  Enlargement  of  the  lateral  lobes  can  be  detected 
by  a  finger  in  the  rectum.  The  rectum  becomes  irritable, 
and  piles  form  or  prolapse  of  the  mucous  membrane  occurs. 
Attacks  of  retention  of  urine  may  occur.  The  bladder  be- 
comes thin  and  distended,  or  hypertrophied,  rigid,  and  fascic- 
ulated. In  rare  cases  true  incontinence  is  caused  by  the 
median  lobe  growing  toward  the  neck  of  the  bladder  and 
preventing  closure.  The  health  breaks  down  because  of 
pain,  restless  nights,  indigestion,  and  disorder  of  the  bowels. 
The  kidneys  may  become  involved  (inflammation  of  the  pel- 
ves or  calyces,  or  surgical  kidney)  and  suppression  may 
occur.  Septic  fev^er  may  arise.  Calculi  may  form  in  the 
bladder.  Death  is  due  to  exhaustion,  suppression  of  urine, 
or  septic  cystitis.  If  a  foul  catheter  is  used,  septic  cystitis 
is  certain  to  occur ;  but  micro-organisms  sometimes  enter 
by  passing  along  the  urethral  mucous  membrane. 

Treatment. — Many  cases  can  be  treated  by  regular  cath- 
eterization. Alexander  has  formulated  several  sound  rules  as 
to  when  catheterization  is  the  proper  treatment.     He  says ; 


836  MODERN  SURGERY. 

if  the  patient  is  intelligent  and  dexterous,  if  cystitis  is  not 
severe,  if  the  amount  of  residual  urine  is  not  very  large,  if 
obstruction  is  not  great,  if  the  bladder  retains  considerable 
expulsive  power,  and  if  catheterization  is  easy  and  painless, 
rely  upon  this  simple  plan  of  treatment.  Prevent  cystitis  by 
emptying  the  bladder  each  evening  with  a  coude  catheter. 
If  there  is  trouble  in  passing  the  catheter,  strengthen  the  in- 
strument by  inserting  a  filiform  bougie  as  a  stylet  (Brinton). 
In  some  cases  a  metal  instrument  with  a  large  curve  is 
used.  Teach  the  patient  to  use  the  instrument  himself 
A  dirty  instrument  may  cause  fatal  infection.  It  is  true  that 
some  people  use  dirty  instruments  for  long  periods  without 
trouble,  but  in  most  cases  there  will  be  trouble  if  it  is 
attempted.  It  is  absolutely  necessary  to  use  only  perfectly 
aseptic  instruments.  Metal  instruments  are  sterilized  by 
boiling  in  water.  Rubber  catheters  can  be  cleansed  by 
washing  with  soap  and  running  water  and  boiling,  or,  after 
washing,  soaking  in  corrosive-sublimate  solution.  Woven 
instruments  can  be  placed  in  a  glass  cylinder,  the  bottom  of 
which  is  like  a  sieve.  This  jar  is  placed  for  twenty-four 
hours  in  a  vessel  which  contains  formalin.  The  vapor  of 
formalin  is  an  excellent  germicide,  and  does  not  injure  the 
catheter.  After  sterilization  the  instruments  are  kept  ready 
for  use  in  a  glass  cylinder  which  contains  calcium  chlorid.^ 
Guyon  scrubs  the  catheters  with  soap  and  water,  dries  them 
outside  and  inside,  places  them  in  a  sealed  jar,  and  ex- 
poses them  to  the  vapor  of  sulphurous  acid  for  forty- 
eight  hours.  If  there  are  three  ounces  of  residual  urine, 
use  the  catheter  only  at  night.  If  there  are  six  ounces, 
use  it  night  and  morning.  If  there  are  more  than  six 
ounces  of  residual  urine,  add  one  more  catheterization 
a  day  for  every  additional  two  ounces  present  until  the 
catheter  is  used  six  times  in  the  twenty-four  hours.  It 
should  never  be  used  oftener  than  this.  Gradual  dilatation 
with  steel  sounds  is  of  benefit,  but  forcible  dilatation  is  not 
advisable.  TeW  the  patient  to  avoid  violent  exercise,  cold, 
damp,  sexual  excitement,  and  the  use  of  alcoholic  liquor, 
prevent  constipation  and  indigestion,  and  direct  him  to  drink 
plenty  of  Poland  water.  A  hot  hip-bath  at  night  adds  to 
his  comfort.  Hot  enemata  are  of  value.  If  a  large  quan- 
tity of  residual  urine  exists,  or  if  cystitis  begins,  wash  out 
the  bladder  daily  with  boric-acid  solution,  or  normal  salt 
solution,  or  nitrate  of  silver  (i  :  12,000),  and  give  urotropin 
or    salol   and    boric    acid   by   the  mouth.     In   some   severe 

1  R.  W.  Frank,  in  Berliner  klifi.   IVock.,  No.  44,  1895. 


DISEASES   OF  GENITO-URINARY  ORGANS.  837 

cases,  if  a  large-size  rubber  catheter  be  tied  in  the  bladder  for 
a  few  days,  great  relief  is  obtained.  Retention  of  urine  can  be 
relieved  by  the  introduction  of  a  coude  catheter  strengthened 
with  a  whalebone,  of  a  silver  instrument  with  a  prostatic  curve, 
or  by  aspiration.  If  the  symptoms  grow  constantly  worse, 
if  the  suffering  becomes  severe,  if  the  patient  cannot  uri- 
nate without  the  use  of  an  instrument,  if  catheterization  is 
painful  or  impossible,  if  the  patient  is  too  careless  or  ignorant 
to  trust  with  a  catheter,  if  only  a  catheter  of  very  small  size 
can  be  introduced,  if  attacks  of  obstinate  retention  occur, 
if  there  is  persistent  cystitis  or  hematuria,  if  the  residual 
urine  gradually  increases  in  amount,  a  radical  operation 
should  be  performed. 

Suprapubic  cystotomy  may  be  performed,  the  opening 
being  kept  permanently  patent  (Hunter  McGuire's  oper- 
ation). 

Suprapubic  prostatectomy  may  be  performed.  After  the 
bladder  is  opened  the  mass  of  prostate  is  enucleated  or  cut 
away  with  scissors  or  with  cutting-forceps.  The  suprapubic 
cut  is  allowed  to  heal.  Perineal  prostatotomy  may  be  per- 
formed, the  gland  being  split  and  perineal  drainage  tempo- 
rarily employed.  McGill's  operation  is  suprapubic  pros- 
tatectomy, the  gland  being  removed  partly  by  enucleation 
and  partly  by  the  employment  of  cutting  rongeur-forceps. 
Fuller  performs  a  suprapubic  cystotomy,  makes  a  small 
incision  through  the  mucous  membrane  of  the  gland, 
enucleates  the  gland  with  the  finger,  and  drains  through 
an  incision  in  the  membranous  urethra.  Belfield  makes  a 
suprapubic  cut  and  a  perineal  cut,  and  with  the  finger  in  the 
perineum  pushes  the  gland  into  easy  reach  of  the  finger  in 
the  bladder. 

Perineal  prostatectomy  may  be  employed.  Some  surgeons 
make  a  curved  incision  across  the  perineum  and  dissect  out 
the  gland.  Nicoll  first  performs  suprapubic  cystotomy, 
opens  the  perineum  down  to  the  prostate,  splits  the  capsule 
of  the  prostate,  inserts  two  fingers  of  the  left  hand  into  the 
bladder,  and  pushes  the  prostate  dow^n  into  the  perineum. 
The  surgeon  enucleates  the  gland  through  the  perineal 
wound  without  damaging  the  mucous  membrane  of  the 
bladder.  Alexander  makes  the  suprapubic  cut  and  uses 
it  for  the  same  purpose  as  Nicoll,  but  he  opens  the  mem- 
branous urethra  on  a  grooved  staff,  enucleates  the  gland, 
and  inserts  a  drainage-tube  through  the  perineal  wound. 
Bottini  of  Padua,  by  means  of  a  special  instrument,  cauter- 
izes the  prostate  repeatedly.     This  instrument  is  shaped  like 


838  MODERN  SURGERY. 

a  catheter  and  carries  a  platinum  blade  which  is  heated  by 
an  electric  current. 

In  1893  J.  William  White  introduced  the  operation  of 
bilateral  orchidectomy.  He  proved  that  removal  of  the 
testicles  causes  a  rapid  shrinking  in  an  enlarged  prostate. 
Part  of  this  shrinking  may  be  due  to  diminution  of  conges- 
tion and  edema,  but  true  atrophy  undoubtedly  occurs.  Very 
remarkable  results  have  been  recorded.  In  most  cases  the 
patient  becomes  absolutely  comfortable.  Some  cases  dis- 
pense entirely  with  the  catheter.  Cystitis  ceases,  and  desire 
to  urinate  frequently  becomes  less  marked.  Unilateral 
orchidectomy  has  been  employed,  but  it  is  not  satisfactory. 
Division  of  the  vas  deferens,  vasectomy,  may  be  employed 
instead  of  orchidectomy.  It  is  slower  in  its  results,  but  just 
as  certain.  In  spite  of  the  great  simplicity  of  orchidectomy 
the  mortality  has  been  considerable  (from  11  to  18  per  cent.). 
In  several  instances  mental  disturbance  has  followed  the 
operation,  but  there  is  no  real  evidence  that  it  was  due  to 
this  special  form  of  operation  and  would  not  with  certainty 
have  followed  any  other. 

Retained  and  Malplaced  Testicle. — The  testicle  may 
be  arrested  in  its  passage  to  the  scrotum  :  it  may  remain  in  the 
lumbar  region  ;  it  may  reach  the  internal  abdominal  ring ;  it 
may  lodge  in  the  inguinal  canal ;  it  may  emerge  from  the 
external  ring,  but  fail  to  enter  the  scrotum ;  or  it  may  pass 
into  unnatural  positions,  as  into  the  perineum  or  the  crural 
canal.  It  may  or  may  not  be  functionally  active.  A  re- 
tained testicle  is  subject  to  attacks  of  orchitis  and  is  apt 
to  become  sarcomatous.  Sometimes  a  testicle  descends 
after  being  retained  for  months. 

Treatment. — If  one  testicle  is  undescended  one  year  after 
birth,  and  the  other  testicle  is  sound,  the  former  should  be 
removed  if  it  is  found  impossible  to  draw  the  gland  into  the 
scrotum  and  fasten  it.  Always  try  to  get  a  retained  gland 
into  the  scrotum. 

Orchitis  is  inflammation  of  the  testicle.  Aaite  orchitis 
may  be  due  to  cold,  wet,  traumatism  or  epididymitis,  gout, 
mumps,  rheumatism,  or  a  specific  fever.  The  testicle  is 
round,  swollen,  tender,  and  ver}^  painful,  the  scrotum  is  red 
and  swollen,  the  tunica  vaginalis  is  filled  with  fluid,  and  there 
is  fever.  Chronic  orchitis  results  from  the  acute  form  or  from 
a  chronic  urethral  inflammation,  and  is  almost  always  com- 
bined with  epididymitis.  Syphilis  or  tubercle  may  be  respon- 
sible for  chronic  orchitis. 

Tlie  treatment  of  the  acute  form  consists  of  rest  in  bed  and 


DISEASES   OF  GENITO-URINAKY  ORGANS.  839 

applications  as  for  epididymitis  (see  below).  The  cJironic 
form  requires  the  removal  of  the  causative  lesion,  a  suspen- 
sory bandage,  inunctions  of  ichthyol  or  •mercurial  ointment, 
and  iodid  of  potassium  by  the  mouth.  Strapping  may  do 
good.     Castration  may  be  required. 

Castration  (Excision  of  a  Testicle). — In  this  operation  an 
incision  is  made  over  the  cord,  commencing  just  outside  the 
external  ring  and  running  down  over  the  base  of  the  tumor. 
Clamp  the  cord  and  divide  near  to  the  ring,  remove  the 
testicle,  ligate  the  spermatic  artery  alone,  and  then  ligate 
the  entire  thickness  of  the  cord.  The  cord  is  sutured  with 
chromic  gut  or  silk.  Drainage  is  not  required.  It  is  often 
advisable  to  remove  a  considerable  amount  of  scrotal  skin. 

epididymitis,  or  inflammation  of  the  epididymis,  is  usu- 
ally due  to  inflammation  of  the  urethra.  It  is  apt  to  occur  in 
the  stage  of  decline  of  a  gonorrhea,  and  is  announced  by  a 
complete  cessation  of  the  discharge.  It  may  result  from  the 
passage  of  a  urethral  instrument,  the  voiding  of  urine  which 
contains  fragments  of  calculi,  or  as  a  complication  of  pros- 
tatic hypertrophy.  Acute  epididymitis  is  characterized  by 
swelling  about  the  testicle,  pain  in  the  groin,  and  tenderness 
over  the  posterior  part  of  the  testicle.  The  pain  becomes 
acute,  swelling  rapidly  increases,  and  the  constitution  sym- 
pathizes. The  swelling  is  due  partly  to  engorgement  of  the 
epididymis  and  partly  to  fluid  in  the  tunica  vaginalis  (acute 
hydrocele).  Chronic  epididymitis  is  usually  linked  with 
orchitis,  and  it  follows  an  acute  attack  or  a  chronic  urethral 
inflammation. 

Treatment  by  puncture  with  an  aseptic  tenotome,  if 
fluctuation  is  marked,  relieves  tension  and  pain.  Leech- 
ing over  the  external  abdominal  ring,  use  of  an  ice- 
bag,  elevation,  lead-water  and  laudanum,  laxatives,  and 
opium  are  used  in  the  acute  stage.  Painting  with  1 5  drops 
of  guaiacol  in  i  dram  of  olive  oil  relieves  the  pain  greatly. 
Strapping  is  employed  as  the  inflammation  subsides.  The 
treatment  of  the  chronic  form  is  the  same  as  that  for  chronic 
orchitis. 

Hydrocele  (chronic  hydrocele)  is  a  collection  of  fluid 
in  the  tunica  vaginalis  testis.  An  enlargement  of  the  testis 
may  cause  .it,  but  in  most  instances  the  cause  is  unknown  and 
no  signs  of  inflammation  exist.  The  fluid  is  albuminous,  but 
it  does  not  coagulate  spontaneously  ;  it  is  thin,  straw-colored, 
and  may  contain  crystals  of  cholesterin.  The  testicle  is  at 
the  lower  and  back  part  of  the  sac.  The  pyriform  mass 
fluctuates,  is  translucent,  grows  from  below  upward,  and  the 


840  MODERN  SURGERY. 

introduction  of  an  exploring-needle  permits  the  yellow  fluid 
to  flow  out. 

Treatment. — Simply  tapping  the  sac  with  a  trocar  is  only 
palliative ;  air  must  run  in  as  fluid  runs  out,  and  suppura- 
tion may  occur,  which  will  be  dangerous  without  drainage. 
Never  tap  a  rigid  sac.  The  injection  of  irritants  should  be 
abandoned,  as  it  exposes  the  patient  to  serious  danger 
because  of  inflammation  occurring  without  provision  for 
drainage.  Hearn  incises  the  sac,  dries  its  interior  with  bits 
of  gauze,  swabs  it  out  with  pure  carbolic  acid,  packs  it  with 
iodoform  gauze,  and  dresses  it  antiseptically.  The  packing 
is  removed  in  twenty-four  hours  and  the  wound  is  allowed 
to  close.  If  the  sac  is  rigid  and  will  not  collapse,  either 
stitch  it  to  the  skin  and  pack  it  or  excise  a  large  portion  of 
its  parietal  layer  and  insert  a  drainage-tube  (Volkmann's 
operation).  It  has  recently  been  proposed  to  tap  the  sac 
with  a  trocar  and  cannula,  to  leave  the  cannula  in  place  as  a 
drain  for  some  days,  and  to  dress  antiseptically. 

Congenital  hydrocele  is  hydrocele  through  an  unclosed 
funicular  process  into  the  tunica  vaginalis.  If  the  pelvis  is 
raised,  the  fluid  runs  back  into  the  peritoneal  cavity,  from 
which  it  originally  came.  The  treatment  is  a  truss  to  oblit- 
erate the  funicular  process. 

Infantile  hydrocele  is  a  collection  of  fluid  in  a  funicular 
process  and  the  tunica  vaginalis,  the  funicular  process  being 
closed  above,  but  not  below.  The  treatment  is  to  puncture 
the  sac  and  to  scarify  the  sac-wall  with  a  needle. 

Bncysted  Hydrocele  of  the  Cord. — In  this  variety  the 
funicular  process  is  obliterated  above  and  below,  but  it  is 
patent  between  these  two  points,  and  fluid  collects.  The 
treatment  is  the  same  as  that  for  infantile  hydrocele.  If  this 
fails,  incise  and  pack. 

Funicular  Hydrocele. — The  funicular  process  is  closed 
below,  but  is  open  above.  Raising  the  pelvis  causes  the 
fluid  to  trickle  back  into  the  peritoneal  cavity.  The  treat- 
ment is  a  truss. 

Encysted  hydroceles  of  the  testicles  and  of  the  epididymis 
may  occur.  Diffused  hydrocele  of  the  cord  is  simply  edema 
of  the  cord.  Hydrocele  of  a  hernia  is  the  distention  of  a 
hernial  sac  with  peritoneal  fluid. 

Hematocele. —  Vaginal  Jiematocele  is  blood  in  the  tunica 
vaginalis,  the  result  of  traumatism,  a  tumor,  or  the  tapping 
of  a  hydrocele.  There  is  a  pyriform  tumor,  which  fluctu- 
ates, but  which  gradually  becomes  firmer ;  the  scrotum  is 
livid,  and  the  testicle  is  below  and  posterior  to  the  tumor. 


AMPUTATIONS.  84 1 

The  encysted  form  of  hematocele  of  the  cord  is  a  hydrocele 
of  the  cord  into  which  bleeding  has  occurred.  The  diffused 
form  is  due  to  extravasation  of  blood  into  the  cellular  sub- 
stance of  the  cord.  E/icysted  hematocele  of  the  testicle  is  due 
to  effusion  of  blood  into  an  encysted  hydrocele  of  the  testicle. 
Parenchymatous  hematocele  is  extravasation  of  blood  into 
the  substance  of  the  testicle. 

The  treatment  of  a  recent  case  of  vaginal  hematocele  is 
to  put  the  patient  to  bed,  support  the  scrotum,  and  apply  an 
ice-bag  over  the  testicle.  If  the  swelling  does  not  soon 
abate,  incise,  irrigate,  and  pack. 

Varicocele  is  varicose  enlargement  of  the  veins  of  the 
pampiniform  plexus.  An  irregular  swelling  exists  in  the 
scrotum  and  extends  up  the  cord.  This  swelling  feels  like 
"  a  bag  of  earth-worms ;  "  it  exhibits  a  slight  impulse  on 
coughing  ;  the  scrotal  skin  and  cremaster  muscle  are  attenu- 
ated ;  the  testicle  lies  at  the  bottom  of  the  swelling  and  is 
softer  and  smaller  than  normal ;  the  swelling  diminishes  on 
lying  down  and  increases  on  standing  or  on  making  pressure 
over  the  external  ring.  There  is  usually  some  discomfort, 
aching,  or  dragging  in  the  testicle  or  the  groin,  and  even 
neuralgic  pain  in  the  cord.  There  is  sometimes  mental  de- 
pression and  hypochondria. 

Treatment. — In  treating  varicocele,  reassure  the  patient : 
tell  him  there  is  no  real  danger  of  impotence ;  order  cold 
shower-baths,  correct  constipation  and  indigestion,  give  occa- 
sional tonics,  and  order  the  patient  to  wear  a  suspensory 
bandage.  If  the  testicle  becomes  much  atrophied,  if  the 
pain  and  the  dragging  are  annoying,  or  if  the  mind  is  much 
depressed,  operate  (see  page  261). 

XXXVII.  AMPUTATIONS. 

An  amputation  is  the  cutting  off  of  a  limb  or  a  portion 
of  a  limb.  Removal  of  a  limb  or  a  portion  of  a  limb  at  a 
joint  is  known  as  "  disarticulation."  Amputation  may  be 
necessary  because  of  the  existence  of  severe  injuiy,  of  gan- 
grene, of  tumors,  of  intractable  disease  of  bones  or  joints, 
of  ulcers  which  will  not  heal,  of  traumatic  aneurysm,  etc. 
A  re-amputation  may  be  required  because  of  the  existence 
of  a  defect  or  disease  in  the  stump. 

Classification. — Amputations  are  classified  as  follows : 
(i )  As  to  time  of  operation  after  the  injury  :  a  primary  ampu- 
tation is  performed  soon  after  the  occurrence  of  the  accident 
— as  soon  as  the  sufferer  reacts  from  shock,  and  before  he 


842 


MODERN  SURGERY. 


develops  fever ;  a  secondary  amputation  is  performed  some 
time  after  the  accident,  suppuration  having  supervened 
(Stokes);  and  an  intermediate  amputation  is  performed  dur- 
ing the  existence  of  fever,  but  before  the  development  of 
suppuration.  (2)  As  to  the  situation,  where  the  bone  is 
divided  or  according  to  which  joint  is  cut  through,  (3)  As 
to  the  form  and  situation  of  the  flap. 

In  performing  an  amputation  maintain  rigid  asepsis ;  com- 
pletely remove  the  hopelessly-damaged  portion ;  sacrifice  as 
little  of  the  sound  tissue  as  possible ;  prevent  hemorrhage 
during  the  amputation,  and  carefully  arrest  it  after  the  opera- 
tion ;  have  enough  sound  tissue  in  the  flap  to  cover  \h&  bone, 
and  enough  skin  to  cover  the  muscles ;  and  secure  drainage 
at  a  dependent  point. 

Hemorrhage  is  prevented  by  the  elastic  bandage  of  Esmarch 
(Fig.  306).  In  an  ordinary  case  apply  this  bandage  from  the 
periphery  to  well  above  the  line  of  the  prospective  incision. 


Fig.  306. — Esmarch's  elastic  bandage. 


Fig.  307. — .Application  of  tourniquet. 


encircle  the  limb  with  the  elastic  band  (not  a  thin  tube),  and 
remove  the  bandage.  The  bandage  and  band,  which  are  asep- 
ticized before  using,  are  applied  to  the  limb,  which  has  been 
carefully  sterilized.  After  the  band  has  been  applied  the  limb 
should  not  freely  or  forcibly  be  moved,  because  of  the  danger 
of  tearing  muscles  which  are  firmly  set  by  the  compressing 
band.  When  elastic  compression  is  used  in  an  operation  the 
surgeon    should  be  very  careful   to   tie   every  visible  vessel. 


AMPUTA  TIONS. 


843 


The  paralysis  of  the  small  vessels  induced  by  pressure  often 
prevents  bleeding,  and  unless  their  mouths  be  found  and  the 
vessels  be  tied  reactionary  hemorrhage  will  occur.  Reac- 
tionary hemorrhage  is  the  great  danger  after  the  use  of  the 
Esmarch  bandage,  and  paralysis  or  sloughing  may  also  fol- 
low its  employment.  If  there  be  an  area  of  suppuration  or 
of  gangrene  or  an  extra-osseous  malignant  growth,  do  not 
apply  the  bandage  as  directed  above.  One  bandage  can 
be  applied  from  the  periphery  to  near  the  lower  border  of 
the  area  of  growth  or  infection,  and  another,  from  near  the 
upper  border  of  this  area,  up  the  limb.  The  contents  of 
the  area  (tumor-cells  and  fluid  or  septic  products)  are  not 
squeezed  into  the  circulation.  In  cases  like  the  abov^e  many 
surgeons  hold  the  extremity  in  a  vertical  position  for  five 
minutes,  lightly  stroking  it  toward  the  body  with  the  hand, 
and  at  once  apply  the  constricting  band.  As  a  matter  of 
fact,  this  plan  satisfactorily  empties  the  limb  of  blood,  and 
it  is  not  necessary  in  any  case  to  force  the  blood  out  by 
elastic  compression.  Some  surgeons  prefer  the  tourniquet. 
Figs.  308  and  309  show  two  forms  of  tourniquet.  To 
apply  Petit's  tourniquet,  place  the  plates  in  contact,  apply 


Fig.  308. — Petit's  spiral  tourniquet 


Charriere's  tourniquet. 


a  small  firm  compress  over  the  artery  and  a  broad  thick 
compress  over  the  outer  surface  of  the  limb,  buckle  the 
tapes  around  the  limb  so  that  the  plate  is  over  the  broad 
pad,  and  tighten  the  tourniquet  by  separating  the  plates 
with  the  screw  (Fig.  307).     When  a  tourniquet  is  applied  to 


844 


MODERN  SURGERY. 


arrest  bleeding  during  transportation,  bandage  the  limb,  sew 
the  compress  pad  to  a  bandage,  and  place  the  plates  of 
the  instrument  over  the  pad.  Signorini's  horseshoe  tourni- 
quet may  be  used  upon  the  brachial  artery.  In  hip-joint 
and  shoulder-joint  amputations  Wyeth's  pins  are  passed, 
and  after  the  limb  is  emptied  of  blood  the  band  is  fastened 
above  them.     These  pins  prevent  the  bands  from  slipping. 

The  instruments  and  appliances  required  are  Esmarch's 
apparatus  or  tourniquet,  amputating-knives,  a  bone-knife, 
scalpels,  saws,  a  lion-jawed  forceps,  bone-cutting  forceps, 
a  periosteum-elevator,  retractors  of  linen,  dissecting-,  hemo- 
static, and  toothed  forceps,  a  tenaculum,  an  aneurysm-needle, 


Fig.  310. — Catlin,  knife,  and  saws  for  amputations. 

a  probe,  scissors,  needles,  ligatures,  sutures  of  silkworm-gut, 
dressings,  bandages,  and  solutions.  A  retractor  has  two  tails 
for  the  thigh  and  arm  and  three  tails  for  the  leg  and  fore- 
arm :  it  is  made  by  taking  a  piece  of  muslin  eight  inches 
wide  and  twelve  inches  long  and  cutting  tails  on  one  side 
eight  inches  in  length. 

Methods  of  Amputating. — Circular  Method  (Fig. 
311). — The  surgeon  should  stand  to  the  right  of  the  limb 
and  use  a  long  amputating-knife 
which  cuts  from  heel  to  point.  After 
an  assistant  has  retracted  the  skin 
the  operator  divides  the  soft  parts 
by  a  series  of  circular  cuts.  Do  not 
cut  at  once  to  the  bone,  but  divide 
the  skin  and  subcutaneous  tissues. 
At  the  retracted  edge  of  the  first  cut 
divide  the  superficial  muscles,  and 
after  these  muscles  retract  divide  the  deep  muscles.  Incise 
the  periosteum  with  a  bone-knife,  push  up  the  periosteum 
with  an  elevator,  and  after  the  application  of  the  retractors 
saw  the  bone,  starting  the  saw  from  heel  to  point.  A 
periosteal  flap  can  be  made  to  cover  the  end  of  the  bone, 
but    it   is    unnecessary.      In   this   amputation   is   formed   a 


Fig.  311. — Amputation  of 
arm  by  the  circular  method 
(Druitt). 


AMPUTATIONS. 


845 


cone  whose  apex  is  the  bone  and  whose  base  is  the  skin- 
edge.  In  one  form  of  circular  amputation  {amputation 
a  la  mancJu'tte)  the  retracted  skin  is  cut  by  a  circular 
sweep  of  the  knife,  a  cuff  of  skin  and  subcutaneous  tissue  is 
freed  and  turned  up.  and  the  muscles  are  cut  circularly  at 
the  edge  of  the  turned-up  cut  (Fig.  312).     The  pure  circular 


Fig.  312. — Circular  amputation  :  dissecting  up  the  skin-flap  (Esmarch). 

amputation  is  performed  on  the  arm  and  the  thigh ;  the 
amputation  a  la  maiichcttc  is  performed  chiefly  through  the 
wrist  and  the  lower  forearm. 

Modified  Circular  Method. — In  this  operation  the  cir- 
cular skin-cut  may  be  modified  by  making  a  vertical  incision 
to  join  the  first  wound,  the  muscles  being  cut  by  a  circular 
sweep  or  by  making  two  vertical  skin-incisions.  Liston's 
modification  consists  in  dissecting  up  two  short  semilunar 
integumentary  flaps  and  in  dividing  the  muscles  circularly. 
This  is   known  as  the  "mixed  method"   (Fig.   313).     The 


Fig.  313. — Modified  circular  amputation  :  skin-flaps  and  circular  through  muscles 
(Esmarch). 

modified  circular  can  be  used  upon  the  thigh,  the  leg,  the 
arm,  and  the  forearm. 


846  MODERN  SURGERY. 

Elliptical  Method. — This  method  stands  midway  between 
the  circular  operation  and  the  operation  by  a  single  flap. 
An  elliptical  incision  is  made  through  the  skin  and  subcu- 
taneous tissues,  the  tissues  are  pushed  up  or  turned  back, 
and  the  muscles  are  divided  circularly  or  cut  partly  by 
transfixion.  This  method  is  employed  particularly  in  certain 
disarticulations. 

Oval  or  Racket  Method. — In  an  oval  amputation  the 
incision  through  the  skin  and  subcutaneous  tissue  is  an  oval 
with  a  pointed  end  or  a  triangle,  and  the  other  parts  down 
to  the  bone  are  cut  from  without  inward.  When  a  longi- 
tudinal incision  down  to  the  bone  (Fig.  318,  a,  b)  extends 
from  the  point  of  the  oval  {a,  b)  the  operation  is  called 
the  "  racket "  amputation.  If  the  longitudinal  cut  joins 
a  circular  cut,  the  operation  is  known  as  a  "  T "  am- 
putation. The  oval  or  racket  operation  is  performed  at 
the  metacarpophalangeal,  metatarsophalangeal,  and  shoul- 
der-joints ;  the  T  operation  may  be  performed  at  the  hip- 
joint. 

Flap  Method. — A  flap  may  be  composed  of  skin  only  or 
of  both  skin  and  muscle,  but  the  skin-flap  must  always  be 
longer  than  the  muscle-flap,  so  that  the  latter  will  be  covered 

by  it.  A  flap  containing  much 
muscle  heals  badly,  but  the  best 
flap  has  a  moderate  amount  of 
muscle  (enough  skin  to  cover 
the  muscle  and  enough  muscle 
to  cover  the  bone).  Flaps  may 
be  single  or  double.  Double 
flaps  may  be  lateral  or  antero- 
posterior, square  or  \S-shaped, 
equal  or  unequal,  and  they  may 
be  cut  by  transfixion  (Fig.  314), 
Fig.  3i4.--Amputation  of^the  thigh  by     ^^  cutting  from  without  inward, 

by  dissection,  or  by  cutting  the 
skin  from  without  inward  and  the  muscles  by  transfixion. 
When  an  amputation  is  completed,  tie  the  main  vessels, 
pull  down  the  nerves  and  cut  them  high  up,  smooth  the 
flaps,  take  off  the  constricting  band,  and  after  arresting 
hemorrhage  apply  sutures.  In  some  cases  the  deep  parts 
are  stitched  with  a  continuous  catgut  suture  and  the  super- 
ficial parts  are  closed  with  silkworm-gut ;  in  other  cases  the 
deep  parts  are  not  stitched  at  all,  the  skin  alone  being 
sutured  with  silkworm-gut.  Drainage-tubes  should  be  used 
except  in  amputations  of  the  fingers  and  toes. 


AMPUTA  TIONS.  847 

Special  Amputations. 

Fingers  and  Hand. — In  amputating  the  thumb  and  in- 
dex finger  save  every  possible  scrap  of  tissue.  In  either  of  the 
fingers,  if  it  be  necessary  to  amputate  above  the  middle  of  the 
middle  phalanx,  the  attachment  of  the  flexor  tendons  will  be 
cut  off  and  the  finger  will  be  liable  to  project  directly  back- 
ward, so  that  it  is  better  with  these  fingers  either  to  disarticu- 
late at  the  metacarpal  joints  or  to  stitch  the  flexor  tendons  to 
the  periosteum.  The  flexor  tendons  have  fibrous  sheaths  ex- 
tending from  the  proximal  end  of  the  distal  phalanx  to  the 
metacarpophalangeal  articulations,  these  sheaths  being  thin 
and  collapsible  opposite  the  joints,  but  being  thick  and  rigid 
opposite  the  shafts  of  the  bone.  The  fibrous  sheath  is  known 
as  the  tlicca,  and  when  it  is  cut  in  an  amputation  it  should  be 
closed,  otherwise  it  may  carry  infection  to  the  palm  of  the 
hand.  The  theca  does  not  exist  over  the  distal  phalanx,  and 
it  is  not  distinctly  visible  over  the  joint  between  the  distal  and 
middle  phalanges.  To  effect  closure  over  the  shaft  of  a  bone, 
strip  up  the  periosteum  and  pass  catgut  sutures  vertically 
through  the  theca  and  the  periosteum  (Treves).  In  amputa- 
tion of  the  fingers  and  the  thumb  an  Esmarch  bandage  is  un- 
necessary, though  pressure  may  be  made  upon  the  arteries 
at  the  wrist.  Only  two  or  three  ligatures  are  necessary. 
Close  with  a  very  few  sutures,  so  as  to  favor  drainage  between 
the  threads. 

The  distal  phalanx  is  best  removed  by  a  long  palmar  flap 
(Fig.  315,  a).     The  palmar  flap  (a)  is  marked  out  by  cutting 
through  the  skin  and  subcutaneous  tissue. 
The  incisions  are  next  carried  to  the  bone, 
the  flap  is  dissected  from  the  bone,  the  fin- 
ger is  strongly  flexed,  a  transverse  incision 
(b)  is  carried  across  the  dorsum  on  a  level     ^''^  oPthl^niTr'*''"" 
with  the  base  of  the  third  phalanx,  the  soft 
parts  are  pushed  back,  the  joint  is  opened,  the  lateral  liga- 
ments  are   cut  from  within   outward,  the   third  phalanx  is 
forcibly  extended,  and  the  remaining  structures  are  cut  from 
below  upward.     The  middle  phalanx  can  be  removed  by  the 
same  method  (c).     The  proximal  phalanx  can  be  removed 
by  a  long  palmar  flap  or  by  a  long  palmar  and  a  short  dorsal 
flap  (d,  e). 

Disarticulation  of  a  metacarpophalangeal  joint  is 
best  performed  by  the  oval  or  racket  method.  The  incision 
upon  the  dorsum  (a)  is  begun  just  above  the  head  of  the 
metacarpal  bone,  is  carried  down  to  beyond  the  base  of  the 


848 


MODERN  SURGERY. 


Fig.  316. — A,  disarticu- 
lation of  a  metacarpopha- 
langeal joint;  c,  amputa- 
tion of  a  finger  with  the 
metacarpal  bone. 


phalanx,  and  involves  the  skin  only  (Fig.  316).  One  incision 
sweeps  around  the  finger  at  the  level  of  the  web,  going  only 
through  the  skin  (b);  the  finger  is  extended  and  the  palmar 
cut  is  carried  to  the  bone ;  each  lateral  incision  is  carried  to 
the  bone  while  the  finger  is  bent  in  the 
opposite  direction,  the  flaps  are  dissected 
back  to  the  joint,  the  finger  is  strongly 
extended,  the  joint  is  opened  fi-om  the 
palmar  side,  and  disarticulation  is  effected. 
Cutting  off  the  head  of  the  metacarpal 
bone  improves  the  appearance  of  the 
stump  but  weakens  the  hand,  hence  in  a 
workingman  it  must  not  be  done  unneces- 
sarily. If  it  is  necessary  to  remove  a 
metacarpal  bone,  the  incision  (c)  is  made 
from  the  carpometacarpal  joint. 

Amputation  of  the  thumb  through 
its  distal  or  proximal  phalanx  is  performed 
identically  as  is  an  amputation  of  a  finger. 
Amputation  of  the  thumb,  with  a  portion  or  the  whole  of  its 
metacarpal  bone,  is  performed  by  the  oval  or  racket  incision. 
Amputation  of  the  wrist-joint  can  be  done  by  the 
circular  method  or  by  a  double  flap.  In  the  double-flap 
amputation  a  dorsal  flap  is  made  by  carrying  a  semilunar 
skin-incision  between  the  styloid  processes  ;  the  skin  is  lifted, 
the  wrist  is  forcibly  flexed,  the  joint  is  opened  by  a  trans- 
verse cut,  and  a  long  semilunar  palmar  flap  which  includes 
only  the  skin  and  fascia  is  made  by  dissection. 

Amputation  through  the  forearm   may  be   effected 
by  the    circular  method  (Fig.    312),  the    modified  circular, 

or  the  flap  operation.  An  ex- 
cellent plan  is  to  make  a 
semilunar  dorsal  skin-flap  and 
a  semilunar  skin-flap  on  the 
flexor  surface.  The  flaps  are 
raised,  the  muscles  are  cut  circularly  (Fig.  317),  the  interos- 
seous space  is  cleared  with  the  knife,  a  three-tailed  retractor  is 
applied,  the  periosteum  is  pushed  up,  and  the  bones  are  sawn 
half  an  inch  above  the  flap.  In  sawing  the  bones,  start  the 
saw  upon  the  radius,  draw  it  from  heel  to  point,  make  a  fur- 
row on  the  radius  and  ulna,  and  saw  both  bones  at  same  time. 
After  sawing,  cut  away  any  irregular  edge  with  bone-pliers. 
In  the  lower  third  Teale's  amputation  may  be  done,  the  dor- 
sal flap  being  the  long  one.  In  Teale's  amputation  rectangu- 
lar flaps  are  made.   The  long  flap  is  equal  in  width  and  length 


Fig.  317. — Modified  circular  amputation 
of  the  forearm  (Bryant). 


AMPUTA  TIOXS. 


849 


to  one-half  the  circumference  of  the  limb  at  the  point  where 
it  is  to  be  sawn.  The  short  flap  is  equal  in  width  to  the  long 
flap,  but  is  only  one-fourth  its  length.  The  two  longitudinal 
cuts  are  at  first  taken  onh-  through  the  skin,  but  the  two 
transverse  cuts  go  at  once  to  the  bone.  The  flaps  are  dis- 
sected up  from  the  interosseous  membrane  and  the  bone.  In 
the  middle  or  the  upper  third  of  a  fleshy  arm  two  semilunar 
skin-flaps  can  be  cut  from  without  inward,  and  the  muscle 
can  be  cut  by  transfixion. 

Disarticulation  of  the  elbow-joint  can  be  done  by 
the  elliptical  method  or  by  a  long  anterior  and  short  poste- 
rior flap.  In  the  latter  operation  the  forearm  is  partly  flexed 
and  a  skin-cut  marks  out  a  long  anterior  flap,  the  knife  being 
entered  opposite  the  external  condyle  and  being  withdrawn 
one  inch  below  the  internal  condyle.  The  muscles,  which 
are  bunched  forward,  are  cut  by  transfixion.  A  posterior 
semilunar  flap  is  made,  which  separates  the  attachments  of 
the  radius,  the  ulna  is  cleared,  and  the  triceps  is  cut  at  its  in- 
sertion (Bell).  Gross  advocated  sawing  through  the  olecranon 
and  the  inner  trochlear  surface. 

Amputation  of  the  arm  is  best  performed  b>'  marking 
out  with  a  knife  two  equal  semilunar  anteroposterior  flaps,. 
the  first  cut  being  carried  through  the  skin  alone,  the  mus- 
cles being  then  transfixed  with  a  long  knife.  Teale's  method 
is  shown  in  Fig.  138.  The  circular  or  the  modified  circular 
amputation  may  be  performed. 

Disarticulation  at  the  Shoulder-joint. — In  this  oper- 
ation WVeth's  pins  must  be  passed  to  hold  the  Esmarch 
band  in  place.  The  anterior  pin  is  entered  at  the  middle  of 
the  lower  margin  of  the  anterior  axillary  fold,  and  emerges 
one  inch  within  the  tip  of  the  acromion.  The 
posterior  pin  is  entered  at  a  corresponding 
point  on  the  posterior  axillary  fold,  and 
emerges  more  posteriorly  than  the  first  pin 
and  an  inch  within  the  tip  of  the  acromion. 
The  Esmarch  band  is  applied  above  the  pins. 

Larrey's  Operation. — In  this  method  of 
shoulder-joint  disarticulation  the  limb  is  held 
from  the  side  and  an  incision  is  made  down 
to  the  bone,  the  incision  beginning  just  below 
and  in  front  of  the  acromion  and  running 
vertically  for  four  inches  down  the  outer  sur- 
face of  the  arm  (Fig.  318,  a  b).  From  the 
center  of  this  incision  an  oval  incision  {cd,  c  c)  is  carried 
around  the  arm,  the  inner  aspect  of  the  oval  reaching  as  low 
54 


Fig.  318. — Ampu- 
tation at  the  shoul- 
der-joint :  a,b,c ,d,e, 
Larrey's  operation ; 
y,  g,  Dupuytren's 
operation. 


850  MODER  N  SUR GER  Y. 

as  the  lower  end  of  the  vertical  cut.  The  oval  incision  at 
first  involves  only  the  skin  and  subcutaneous  tissues.  The 
anterior  structures  are  divided  close  to  the  bone,  and  the 
posterior  structures  are  next  cut.  To  di.sarticulate,  cut  the 
capsule  transversely  upon  the  head  of  the  bone;  while  the 
arm  is  rotated  outward  cut  the  subscapularis,  and  while  the 
arm  is  rotated  inward  cut  the  supraspinatus  and  infraspinatus 
and  the  teres  minor.  Cut  away  any  tissue  holding  the  hu- 
merus to  the  body;  cut  away  hanging  nerves,  capsule-frag- 
ments, and  tissue-shreds,  and  sew  up  the  wound  vertically. 
Bell  advises  an  oval  incision  with  a  racket  handle.  Spence 
used  an  anterior  racket  incision. 

Dupu37-tren's  Method. — In  Dupuytren's  shoulder-joint  dis- 
articulation a  U-shaped  flap  is  marked  out  by  a  skin-incision 
(Fig.  318,/^).  If  the  amputation  is  to  be  at  the  right  shoul- 
der the  arm  is  carried  across  the  chest ;  the  knife  is  entered  at 
the  root  of  the  acromion,  follows  the  margin  of  the  deltoid, 
and  is  withdrawn  at  the  coracoid  process,  the  arm  being 
gradually  abducted  and  pulled  off  from  the 
chest.  If  the  left  shoulder  is  to  be  ampu- 
tated, the  procedure  is  reversed  (Treves). 
The  knife  now  cuts  through  the  deltoid  and 
raises  a  flap  composed  of  this  muscle,  the 
shoulder-joint  is  exposed,  and  disarticulation 
is  effected  as  in  Larrey's  method.  The  knife 
is  passed  down  back  of  the  ^bone  and  a  short 
internal  flap  is  cut.  Lisfranc's  amputation  is 
by  transfixion  with  the  formation  of  an  ante- 
rior and  a  posterior  flap,  and  can  be  performed 
very  rapidly,  but  only  a  most  skilful  surgeon 
should  attempt  it. 
Fig. 319-Am-        Amputation  of  the  Toes  and  the  Foot. 

putation  01  meta-  ^ 

tarsal  bones.  — Ouly  in  the  great  toe  is  partial  amputation 

performed,  and  it  is  effected  by  the  formation  of 
a  long  plantar  flap,  just  as  a  long  palmar  flap  is  formed  from 
the  finger.  Amputation  at  the  metatarsophalangeal  joints 
is  performed  by  an  oval  or  racket  incision  (Fig.  319,  c). 
Amputation  of  a  toe  with  removal  of  its  metatarsal  bone  is 
shown  in  Fig.  319,  «  <5  and  d  c. 

Amputation  at  the  Tarsometatarsal  Articulation. 
— Lisfranc's  method  (after  Treves). — In  order  to  ampu- 
tate the  right  foot  by  this  method  begin  an  incision  on  the 
outer  border  of  the  foot,  behind  the  tubercle  of  the  fifth 
metatarsal  bone ;  carry  the  incision  forward  one  inch  and 
sweep  it  across  the  foot  half  an  inch  below  the  tarsometa- 


AMPUTA  TIONS. 


851 


tarsal  articulations ;  bring  the  incision  to  the  inner  edge  of 
the  foot,  half  an  inch  in  front  of  the  tarsal  articulation  of  the 
big  toe,  and  carry  the  cut  straight  along  the  inner  margin 
of  the  foot  until  it  reaches  a  point  three-fourths  of  an  inch 
above  the  articulation  of  the  metatarsal  bone  of  the  great 
toe.  A  very  short  semilunar  dorsal  skin-flap  is  thus 
formed.  After  the  skin-flap  is  dissected  back  for  a 
quarter  of  an  inch  the  tendons  are  divided,  and  the  flap, 
which  now  contains  all  the  soft  parts,  is  dissected  back  to 
above  the  joint.  A  long  plantar  flap  is  cut,  reaching  from 
the  origin  of  the  first  flap  to  the  necks  of  the  metatarsal 
bones.  The  skin-flap  is  dissected  up  until  the  hollow 
behind  the  heads  of  the  metatarsal  bones  is  reached,  when, 
with  the  toes  in  extension,  the  tendons  are  cut  across  and 
a  flap  composed  of  all  the  soft  parts  is  dissected  up  to 
above  the  tarsometatarsal  joint.  Fig.  320  shows  the  line  of 
Lisfranc  at  the  tarsometatarsal  articu- 
lation. The  joint  is  opened  from  the 
outer  side  according  to  the  following  rule  : 
in  separating  the  fifth  metatarsal  direct 
the  edge  of  the  knife  toward  the  distal 
end  of  the  first  metatarsal ;  in  separating 
the  fourth  metatarsal  direct  the  knife 
toward  the  middle  of  the  first  metatar- 
sal ;  in  separating  the  third  metatarsal 
carry  the  knife  almost  directly  across. 
The  separation  is  facilitated  by  bending 
down  the  front  of  the  foot,  and  at  the  same 
time  the  tendons  of  the  peroneus  brevis 
and  tertius  are  divided.  Open  the  joint 
between  the  first  metatarsal  and  the 
inner  cuneiform  bone,  turning  the  knife 
toward  the  middle  of  the  shaft  of  the  fifth  metatarsal,  and 
at  the  same  time  divide  the  tibialis  anticus  muscle.     Treves 


Fig.  320. — Lines  in  am- 
putations    of     the     foot 

(Gross). 


Fig.  321. — Lisfranc's  amputation  :  first  step  (Guerin) 


says  that  in   disarticulation   of  the    second   metatarsal  the 
knife  is  to  be  held  as  a  trocar,  it  is  to  be  thrust  between  the 


852 


MODERN  SURGERY. 


base  of  the  first  and  second  metatarsal  bones  until  the  point 
strikes  bone  (Fig.  321),  and  is  then  to  be  raised  to  a  perpen- 
dicular and  the  cut  is  to  be  made  toward  the  external  malle- 
olus to  sever  the  ligament  of  Lisfranc  (Fig.  322).     Divide 


Fig.  322. — Lisfranc's  amputation  :  second  step  (Guerin). 

any  remaining  ligaments,  and  also  the  tendon  of  the  ^ero- 
neus  longus  muscle.  The  skin-incisions  in  the  left  foot  are 
begun  on  the  inner  side,  and  in  disarticulating  the  tarsal 
joint  of  the  great  toe  is  first  opened.  Fig.  323  shows  the 
parts  after  disarticulation  at  the  line  of  Lisfranc. 

Hey's  Method. — In  Hey's  method  the  incision  is  practi- 
cally the  same  as  that  for  Li.sfranc's  amputation.  The  four 
external  metacarpal  bones  are  disarticulated,  but  the  first 
metatarsal  is  removed  by  sawing  a  portion  of  the  internal 
cuneiform  bone.  Guerin  advised  sawing  all  the  bones  across. 
Skey  advised  the  division  of  the  head  of  the  second  meta- 
tarsal.    Fig.  320  shows  the  line  of  Hey. 

Amputation  through  the  Middle  Tarsal  Joint. — 
Chopart's     Amputation.  —  Make     a     transverse     incision 


Fig.  323. — The  parts  after  Lisfranc's 
amputation  (Bernard  and  Huette^. 


Fig.  324. — The  parts  after  amputation  by  Cho- 
part's method  (Bernard  and  Huette). 


through  the  skin  of  the  instep,  two  inches  below  the 
ankle-joint;  cut  the  tendons  and  muscles,  expose  the  tar- 
sus, and  make   on  each  side  a  small  longitudinal  incision 


AMPUTATIONS. 


853 


reaching  to  below  and  in  front  of  the  corresponding  malle- 
olus. The  flap  thus  formed  is  retracted.  The  plantar  flap 
is  made  as  in  Lisfranc's  amputation.  Open  the  astragalo- 
scaphoid  joint,  then  the  calcaneocuboid  joint,  and  disarticu- 
late. Fig.  320  shows  the  line  of  Chopart.  Fig.  324  shows 
the  parts  after  Chopart's  disarticulation.  In  amputation 
through  the  tarsus  Forbes  of  Toledo  advises  making  flaps 
as  in  Chopart's  amputation,  disarticulating  the  scaphoid 
from  the  cuneiform  bones,  and  sawing  through  the  cuboid. 
Fig.   320  shows  the  line  of  Forbes. 

Amputation  at  the  Ankle-joint. — Syme's  Method. — 
The  foot  is  held  at  a  right  angle  to  the  leg,  and  a  skin- 
incision  is  carried,  from  just  below  the  external  malleolus, 
straight  across  or  a  little  backward  across  the  sole  to  a 
corresponding  point  on  the  opposite  side.  Do  not  take 
this  incision  near  to  the  inner  malleolus,  as  to  do  so  will 
endanger  the  posterior  tibial  artery.  The  incision  is  carried 
to  the  bone,  the  flap  being  pushed  back  and  separated  from 
the  bone  by  means  of  a  strong  knife  and  the  thumb-nail  until 
the  tuberosity  of  the  os  calcis  has  been  reached.  The  foot 
is  now  extended  and  a  transverse  cut  is  made  across  the 
dorsum,  joining  the  two  ends  of  the  first  incision  ;  the  ankle- 
joint  is  opened,  the  lateral  ligaments  are  cut,  disarticulation 
is  effected,  and  the  foot  is  finally  completely  removed  by 
severing  the  tendo  Achillis.  A  thin  piece  of  bone  including 
both  malleoli  is  sawn  from  the  tibia  and  fibula.  The  flap  is 
perforated  posteriorly  to  secure  drainage. 


Fig.  325.— Lines  of  section  of  the  os  calcis  and  the  bones  of  the  leg  in  Pirogoff's 
amputation. 

Pirogoff's  Method. — In  this  method  of  ankle-joint  ampu- 
tation the  incisions  are  the  same  as  those  for  Syme's  ampu- 


854 


MODERN  SURGERY. 


Fig.  326. — Sedillot's 

amputation  of  the  leg 
(Wyeth). 


tation.  Do  not  dissect  the  flap  from  the  posterior  portion 
of  the  OS  calcis,  but  saw  off  this  bony  projection  obHquely 
and  leave  it  adherent  to  the  tissues.  The  saw  is  used  after 
disarticulation  of  the  ankle-joint;  it  is  passed  behind  the 
astragalus,  cutting  downward  and  forward. 
The  ends  of  the  tibia  and  fibula  are  sawn 
off,  and  the  sawn  os  calcis  is  brought  into 
contact  with  the  sawn  tibia  and  fibula.  The 
lines  a  and  b  (Fig.  325)  show  the  sections 
made  by  the  saw. 

Amputations  of  the  I^eg. — In  am- 
putations of  the  leg  by  the  long  anterior 
flap,  cut  through  the  skin,  dissect  up  the 
anterior  muscles  with  the  flap,  and  cut  all 
the  posterior  tissues  with  a  single  trans- 
verse sweep.  Amputation  by  the  rectan- 
gular flap,  Teale's  method,  is  very  useful 
(see  page  848).  The  long  flap  is  anterior, 
and  is  in  length  and  breadth  equal  to  one- 
half  the  circumference  of  the  limb.  The 
short  flap  is  one-fourth  the  length  of  the 
long  flap.  The  flaps  are  dissected  up,  the 
bones  are  sawn,  the  long  flap  is  turned  upon  itself,  and  its 
edges  are  sutured  to  the  edges  of  the  short  flap. 

Sddillot's  leg-amputation  (Fig.  326)  is  by  a  long  exter- 
nal flap.  A  longitudinal  incision  is  made  along  the  inner 
edge  of  the  tibia,  the  tissues  are  drawn  toward  the  fibula, 
a  knife  is  introduced  and  passed  to  the  outer  edge  of  the 
tibia,  just  touching  the  fibula,  and  is  brought  out  posteriorly, 
thus  transfixing  the  calf-muscles  and  cutting  an  external  flap. 
A  convex  incision  is  made  on  the  inner  side,  the  bones  are 
cleared  and  are  sawn  one  inch  above  the  flaps,  half  an  inch 
more  being  taken  from  the  fibula  than  from  the  tibia,  and 
the  tibia  being  bevelled  anteriorly. 

Modified  Circular  Amputation  of  the  Leg". — Cut  semi- 
lunar skin-flaps,  lay  them  back,  and  cut  circularly  to  the 
bone  at  the  edge  of  the  turned-up  flap.  Another  method 
of  modified  circular  amputation  is  by  adding  to  the  circular 
cut  a  vertical  incision  down  the  front  of  the  leg.  In  sawing 
the  bones  of  the  leg  the  surgeon,  who  stands  to  the  outer 
side  of  the  right  leg  or  to  the  inner  side  of  the  left  leg, 
divides  the  fibula  first,  and  at  a  higher  level  than  the  tibia, 
and  bevels  the  anterior  surface  of  the  tibia.  In  sawing  the 
left  fibula  the  saw  points  to  the  floor ;  in  sawing  the  right 
fibula  it  points  to  the  ceiling. 


AMPUTA  TIONS.  855 

Amputation  of  the  Leg-  by  a  Long-  Posterior  and  a  Short 
Anterior  Flap. — In  this  operation  a  posterior  U-shaped  flap 
is  made,  equal  in  length  and  breadth  to  the  diameter  of 
the  limb.  The  skin-incision  is  begun  one  inch  below  the 
point  where  the  bone  is  to  be  sawn,  and  behind  the  inner 
edge  of  the  tibia,  and  is  carried  to  a  point  posterior  to  the 
peronei  muscles.  The  gastrocnemius  muscle  is  divided  trans- 
versely at  the  level  of  the  flap,  the  soft  parts  on  either  side 
in  the  line  of  the  flap  being  cut  to  the  bone.  Through  these 
vertical  cuts  the  muscles  are  lifted 
from  the  bones  and  are  divided 
through  their  lower  part  by  cut- 
ting from  within  outward.  The 
anterior  flap  is  formed  by  making 
a  semilunar  skin-flap  and  by  cut- 
ting  the  muscles    across  at  its   re-       F'G-   3f7.-Amputation  of  the  leg  by 

°  ,  ,  ,  a  long  posterior  flap  (Gross). 

tracted  edge  (rig.  327).  Ampu- 
tation of  the  h'g  by  lateral  flaps  is  not  a  popular  operation,  as 
it  offers  too  much  encouragement  to  subsequent  protrusion 
of  the  bone.  Bier  endeavors  to  broaden  the  support  after 
amputation  by  performing  a  cuneiform  osteotomy  and  bend- 
ing the  lower  fragment  to  a  right  angle  with  the  upper,  and 
obtaining  union  of  the  fragments. 

Amputation  just  below  the  Knee. — The  seat  of  election 
is  one  inch  below  the  tuberosities.  No  muscle  is  needed  in 
the  flap.  Cut  two  flaps  of  skin,  equal  in  size  and  semilunar 
in  shape,  these  flaps  beginning  anteriorly  two  inches  below 
the  tuberosity  of  the  tibia.  One  flap  is  antero-external  and 
the  other  is  postero-internal.  The  flaps  are  pulled  up,  the 
anterior  muscles  are  cut  as  high  up  as  possible,  and  the  pos- 
terior muscles  are  cut  through  the  middle  of  the  portion  ex- 
posed (Bell).  The  bone  is  sawn  one  inch  below  the  tuber- 
osity. 

Disarticulation  of  the  Knee. — In  disarticulation  by  the 
long  anterior  flap,  make  a  long  anterior  skin-flap,  incise  the 
ligament  of  the  patella,  turn  up  the  flap  with  the  patella, 
open  the  joint,  and  complete  the  disarticulation  by  cutting 
from  within  outward  and  downward.  The  knee  may  be  dis- 
articulated by  means  of  a  long  anterior  and  a  short  posterior 
flap. 

Amputation  through  the  Femoral  Condyles. — Syinc's 
Method  by  a  Long  Posterior  Flap. — Carry  a  skin-incision,  with 
a  very  slight  downward  curve  from  one  condyle  to  the  other, 
across  the  middle  of  the  patella.  Cut  down  to  the  bone, 
retract  the  flap,  and  cut  the  quadriceps  above  the  patella. 


856  MODERN  SURGERY. 

Insert  a  long  knife  at  one  angle  of  the  wound,  pass  it  back 
of  the  femur,  and  make  it  emerge  at  the  opposite  angle,  cut- 
ting a  posterior  flap  eight  inches  long.  Retract  the  posterior 
flap,  clear  for  sawing,  and  section  the  condyles  horizontally. 
Garden  made  a  curved  section  of  the  condyles  at  their  widest 
part.  In  children  Buchanan  showed  that  we  can  easily  sepa- 
rate the  lower  femoral  epiphysis.  In  Gritti's  supracondyloid 
amputation  an  oblique  incision  is  made.  The  upper  end  of 
the  incision  is  posterior  and  just  above  the  condyles.  Its 
lower  end  is  anterior  and  two  finger-breadths  below  the 
patella  (Kocher).  The  ligament  of  the  patella  is  cut,  the 
flap  is  turned  up,  the  femur  is  sawn  at  the  base  of  the 
condyles,  the  articular  face  of  the  patella  is  sawn  off,  and 
the  sawn  patella  is  fastened  to  the  sawn  femur  and  the  flaps 
are  sutured.  Sabanejeff  makes  an  anterior  flap,  opens  the 
knee-joint  from  behind,  saws  the  condyles  at  their  broadest 
part,  takes  a  bone-flap  from  the  anterior  portion  of  the  tibia 
and  fastens  it  to  the  femur. 

Amputation  of  the  Thigh. — In  thigh-amputation  in  the 
lower  third  either  a  flap  or  a  circular  operation  may  be  per- 


FiG.  328. — Amputation  of  the  thigh  (Bryant). 

formed.  In  a  double-flap  operation  a  semilunar  skin-incision 
should  be  made  from  without  inward,  and  the  muscles  should 
be  cut  by  transfixion  (Fig.  328).  In  the  lower  third  Teale's 
flap  or  the  long  anterior  flap  may  be  employed.  The  ampu- 
tation by  a  long  anterior  flap  consists  in  making  a  lengthy 
skin-flap,  reflecting  it,  cutting  the  anterior  structures  to  the 
bone,  again  entering  the  long  knife  at  one  angle  of  the  incision, 
pushing  it  back  of  the  femur,  bringing  it  out  at  the  other 
angle,  and  cutting  the  structures  behind  the  bone  directly 


AMPUTA  TIONS. 


857 


backward.  Bell  amputates  by  a  long  anterior  semilunar 
flap  and  a  short  posterior  flap.  In  amputations  in  the 
upper  two-thirds  of  the  thigh  the  best  plan  is  to  mark 
out  equal  anterior  and  posterior  semilunar  skin-flaps,  di- 
vide the  skin  with  a  scalpel,  enter  the  long  knife  at  one 
angle  of  the  anterior  flap,  bring  it  out  at  the  other  angle, 
and  cut  the  muscles  by  transfixion.  Cut  the  posterior  flap 
in  the  same  manner.  Some  surgeons  prefer  a  long  ante- 
rior semilunar  flap  and  a  'short  posterior  semilunar  flap. 
The  pure  circular  amputation  is  not  adapted  to  the 
thigh. 

Disarticulation  at  the  Hip-joint. — Disarticulation  at  the 
hip-joint  can  be  effected  while  the  circulation  is  controlled 
by  Macewen's  method  of  compression  of  the  aorta  (Fig.  329). 


Fig.  329. — Macewen's  method  for  compression  of  the  abdominal  aorta  {American  Text-Book 

of  Surgery). 


The  weight  of  the  assistant's  body  is  thrown  upon  the 
patient's  aorta  by  the  right  fist,  placed  slightly  to  the  left  of 
the  umbilicus.  McBurney  has  suggested  the  prevention  of 
bleeding  by  making  a  small  abdominal  incision  and  having 
an  assistant  make  direct  digital  pressure  upon  the  iliac 
artery.  In  the  bloodless  method  of  Wyeth  (Fig.  330)  the 
band   of  the    Esmarch    apparatus  is   held    up    by  Wyeth's 


858  MODERN  SURGERY. 

pins,  the  outer  pin  being  inserted  one  and  a  half  inches 
below  and  a  little  internal  to  the  anterior  superior  spine 
of  the  ilium,  and  brought  out  just  back  of  the  great  tro- 
chanter. The  inner  pin  is  entered  one  inch  below  the 
level  of  the  crotch,  and  internal  to  the  saphenous  opening, 
and  it  emerges  one  and  a  half  inches  in  front  of  the  tuber- 
osity of  the  ischium.  The  hip  is  brought  well  over  the  edge 
of  the  table,  a  circular  incision  is  made  down  to  the  deep 
fascia  six  inches  below  the  constricting  band,  and  is  joined  by 
a  longitudinal  skin-cut  reaching  from  the  band  to  the  level 
of  the  circular  incision,  and  the  cuff  is  reflected  to  the  level 
of  the  lesser  trochanter.  The  muscles  are  cut  by  a  circular 
sweep  at  the  level  of  the  retracted  cuff,  the  capsule  is  opened 
freely,  the  cotyloid  ligament  is  cut  posteriorly,  the  thigh  is 
bent  upward,  forward,  and  inward  to  dislocate  the  head  of 
the  bone,  and,  using  the  thigh  as  a  handle,  the  round  liga- 
ment is  incised  and  the  limb  removed.  After  ligating  the 
vessels  and  introducing  tubes  the  flaps  are  sewn  together  ver- 
tically.    The  old  transfixion  operation  is  practically  extinct 


Fig.  330. — Amputation  at  the  hip-joint :  Wyeth's  bloodless  method. 

A  "X -amputation  may  be  employed.  It  consists  of  an  external 
straight  incision  down  to  the  bone,  starting  over  the  great 
trochanter,  down  the  outer  side  of  the  limb,  and  a  circular 
incision  through  the  skin  five  inches  below  the  constricting 
band,  the  muscles  being  cut  by  a  circular  sweep  at  the  level 
of  the  retracted  skin.  This  method  affords  easy  access  to 
the  joint.  The  bloodless  method  of  Wyeth,  as  applied  to 
the  hip-joints  and  shoulder-joints,  is  one  of  the  most  notable 
modern  advances  in  the  art  of  surgery.     Larrey  amputated 


DISEASES   OF   THE  BREAST.  859 

by  lateral  flaps,  and  Listen  by  anteroposterior  flaps.  For- 
neaux  Jordan's  method  consists  in  dividing  the  soft  parts 
low  down,  tying  the  bloodvessels  on  the  face  of  the  stump, 
shelHng  out  the  femur  from  the  soft  parts,  and  disarticulating. 

XXXVIII.  DISEASES   OF   THE    BREAST. 

Mammillitis  and  Fissure. — The  nipple  may  inflame 
as  a  result  of  injury,  but  the  condition  is  rarely  encoun- 
tered except  in  a  woman  who  is  nursing  a  baby.  It  is  most 
common  after  a  first  pregnancy,  when  the  nipple  is  deformed 
or  when  the  skin  is  delicate.  The  nipple  is  slightly  injured 
during  nursing,  and  the  epithelium  is  macerated  by  the  milk 
and  saliva.  If  the  inflammation  is  not  arrested,  an  area  ex- 
coriates or  an  irritable  ulcer  forms  (a  fissure).  This  fissure 
is  often  surrounded  by  an  area  of  acute  inflammation,  and 
nursing  causes  intense  agony.  Because  of  the  pain  the 
mother  is  apt  to  extend  the  intervals  between  nursing,  and 
as  a  consequence  the  breasts  become  swollen  with  retained 
milk.  The  ulcer  not  unusually  bleeds  when  taken  by  the 
child.  Besides  the  fact  that  a  fissure  causes  pain  to  the 
mother,  it  often  leads  to  grave  trouble.  It  is  a  suppurating 
area,  and  as  such  may  lead  to  abscess  of  the  mother's 
breast,  or  may  impair  the  health  of  the  nursing  child. 

Prevention  of  Fissure. — During  pregnancy  the  nipples 
should  be  carefully  attended  to.  They  should  be  washed 
often  in  sterile  water  and  bathed  in  alcohol,  and  if  retracted 
ought  to  be  drawn  out  repeatedly.  During  lactation  the 
nipples  are  washed  in  sterile  water,  dried,  and  dusted  with 
borated  talc  powder  as  soon  as  an  act  of  nursing  is  com- 
pleted. Washing  the  nipples  regularly  with  the  following 
solution  tends  to  prevent  the  formation  of  a  fissure :  iodid 
of  mercury,  gr.  ij ;  alcohol,  sjss ;  glycerin  and  distilled 
water,  ad  a  pint  (Lepage).  If  a  small  abrasion  appears, 
order  the  woman  to  wear  a  nipple-shield  during  nursing, 
and  after  each  act  of  nursing  to  wash  the  part  with  hot 
sterile  water,  dr}%  and  dust  borated  talc  over  the  surface.  If 
a  fissure  forms,  wean  the  child  at  once,  and  dry  up  the  milk 
in  both  breasts.  It  is  useless  to  try  to  dry  it  up  in  one 
breast.  Milk  may  be  dried  up  by  applying  ointment  of  bella- 
donna locally  and  administering  iodid  of  potassium  inter- 
nally; by  strapping  the  breasts  with  adhesive  plaster  (Parker); 
or  by  applying  to  the  nipples  six  times  a  day  a  5  per  cent,  so- 
lution of  cocain  in  equal  parts  of  glycerin  and  water  (Joise). 
The  fissure  is  not  treated  by  ointments.     These  preparations 


86o  MODERN  SURGERY. 

are  septic,  prevent  drainage,  and  aggravate  maceration.  Wash 
the  fissure  twice  a  day  with  peroxid  of  hydrogen,  dress  it  with 
gauze  wet  in  boric-acid  solution  (gr.  x  to  3J  of  water),  and 
cover  the  dressing  with  waxed  paper.  If  the  fissure  resists 
treatment,  touch  it  with  lunar  caustic. 

Acute  Mastitis  and  Abscess. — Acute  inflammation  of 
the  breast,  as  a  result  of  injury  of  the  breast  or  nipple,  may 
occur  in  either  sex  at  any  time  of  life.  Very  commonly  in 
both  sexes  a  few  days  after  birth  the  breast  becomes  dis- 
tended with  a  material  which  in  reahty  is  m.ilk.  The  fluid 
is  usually  small  in  quantity.  The  process  is  physiological, 
and,  as  a  rule,  ceases  spontaneously  (GuelHot).  If  it  lingers, 
the  application  of  belladonna  ointment  will  stop  secretion. 
If  the  nurse  meddles  with  and  tries  to  squeeze  out  the  fluid, 
acute  mastitis  is  apt  to  arise  in  one  gland,  or  occasionally  in 
both.  The  skin  of  the  breast  reddens,  the  gland  swells  and 
becomes  tender  and  painful,  the  child  loses  its  appetite  and 
becomes  feverish,  restless,  and  sleepless.  Such  a  condition 
is  treated  by  the  local  use  of  lead-water  and  laudanum.  If 
pus  forms,  the  local  signs  and  constitutional  symptoms  are 
aggravated.  Evacuate  the  pus,  dress  with  hot  antiseptic 
fomentations,  and  be  sure  that  the  child  is  well  nourished. 
Tonics  and  stimulants  are  indicated. 

A  condition  identical  with  the  secretory  activity  of  the 
glands  of  the  new-born  may  occur  in  either  sex  at  puberty. 
The  methods  of  treatment  are  the  same  in  both  cases.  As  a 
matter  of  fact,  rarely  more  than  one  lobule  at  this  period  in- 
flames, and  suppuration  is  most  unusual. 

Mastitis  is  most  usually  met  with  in  a  woman  who  is  nurs- 
ing a  child,  and  is  due  to  bacterial  infection.  Primipara  are 
particularly  liable  to  develop  mastitis.  So  are  women  with 
deformed  nipples.  In  many  cases  an  abrasion  of  the  nipple 
exists,  and  through  this  breach  of  continuity  organisms  gain 
entrance  to  the  breast-tissue.  The  abrasion  may  be  so  slight 
that  it  can  only  be  detected  when  the  nipple  is  examined 
through  a  magnifying-glass  (Marmaduke  Shield).  Strepto- 
coccic infections  are  very  generally  due  to  inoculation  of  a 
fissure  of  the  nipple.  Organisms  may  pass  up  the  milk-ducts, 
coagulating  the  milk  and  penetrating  through  the  walls  of 
the  acini.  Staphylococci  usually  adopt  this  route  in  reaching 
the  breast-tissue.  Occasionally  causative  organisms  reach 
the  breast  through  the  arteries  (in  septicemia  and  in  septic 
wounds  of  the  genital  organs). 

Symptoms. — There  are  pain,  swelling,  and  tenderness  in 
the  breast,  and  in  most  cases  a  fissure  or  abrasion  exists. 


DISEASES   OF   THE  B  HE  AST.  86 1 

There  is  a  febrile  condition.  Occasionally  a  chill  ushers  in 
the  attack. 

Treatment. — Stop  nursing.  Arrest  the  secretion  of  milk. 
Treat  the  nipple  as  advised  on  page  859.  Support  the 
breast  and  apply  ichthyol  ointment  or  lead-water  and  laud- 
anum. 

A  mastitis  may  undergo  resolution  ;  it  may  terminate  in  or- 
ganization and  induration  ;  it  may  eventuate  in  suppuration. 

Acute  abscess  of  the  breast  follows  an  acute  mastitis. 
There  may  be  but  one  area  of  suppuration,  or  multiple  foci 
may  exist,  which  eventually  fuse.  The  symptoms  of  mas- 
titis, local  and  constitutional,  are  greatly  aggravated.  After 
a  time  the  skin  becomes  dusky  and  edematous.  The  axillary 
and  superficial  cervical  glands  enlarge.  The  abscess  will 
eventually  open  spontaneously  at  one  or  more  points,  leaving 
branching  fistulse.  A  superficial  abscess  is  situated  just 
beneath  the  nipple,  and  pus  may  flow  from  the  nipple. 

An  intramammary  abscess  is  in  the  depths  of  the  gland. 
There  are  often  multiple  foci  of  suppuration.  Nodules  are 
felt  in  the  gland,  pus  may  run  from  the  nipple,  but  cutaneous 
redness  is  late  in  appearing. 

Retromammary  abscess  is  a  rather  rare  condition.  It  may 
occur  alone  or  be  associated  and  connected  with  an  area  of 
intramammary  suppuration.  This  condition  may  result  from 
metastasis  or  from  caries  of  a  rib.  The  breast  is  lifted  up 
by  the  fluid  beneath  it. 

Treatment. — Open  a  superficial  abscess  by  an  incision 
radiating  from  the  nipple.  Treat  as  any  other  acute 
abscess.  An  intramammary  abscess  should  be  opened 
by  a  radiating  incision,  and  pockets  of  pus  should  be  broken 
into  with  the  finger.  An  examination  is  made  to  determine 
if  a  retromammary  abscess  also  exists.  If  this  is  found  to 
be  the  case,  an  incision  is  made  at  the  point  of  junction  of 
the  thorax  and  mammary  gland,  and  at  the  lower  border 
of  the  gland.  The  gland  is  raised  from  the  chest-wall,  the 
pus  evacuated,  and  a  drainage-tube  is  inserted.  If  retro- 
mammary abscess  exists  alone,  make  the  last-named  incision 
in  the  first  place. 

Chronic  Mastitis. — This  condition  may  be  present  in 
only  a  portion  of  the  breast,  or  may  attack  many  lobules 
(lobular  mastitis).  The  ordinary  form  may  arise  after  weaning 
a  child,  or  may  be  due  to  a  blow,  to  the  pressure  of  corsets, 
or  to  numerous  slight  traumatisms.  It  may  occur  in  the 
young,  the  middle  aged,  or  the  old.  The  patient  has  slight 
pain  at  times  in  the  gland.      Examination   detects   a   firm, 


862  MODERN  SURGERY. 

elastic  area,  which  is  somewhat  tender  and  does  not  present 
distinct  edges.  The  skin  is  not  adherent  to  the  mass  unless 
suppuration  occurs.  If  the  mass  is  pressed  against  the  chest 
by  the  surgeon's  fingers,  it  becomes  evident  that  no  real 
tumor  exists. 

Treatment. — Remove  any  cause  of  irritation.  Support 
the  breast  in  a  sling.  Apply  ichthyol  ointment.  During 
the  night  employ  a  hot-water  bag.  If  pus  forms,  treat 
as  before  directed. 

Chronic  lobular  mastitis  is  a  condition  in  which 
numerous  lobules  become  indurated.  The  real  cause  of 
this  condition  is  unknown.  It  may  occur  at  any  age  after 
puberty,  and  often  attacks  both  breasts.  Such  a  breast 
is  apt  to  be  painful,  especially  at  the  menstrual  periods ;  it 
feels  unnatural,  solid,  and  careful  examination  detects  numer- 
ous indurated  areas,  each  of  which  is  of  small  size.  At 
the  menstrual  period  the  breast  enlarges  and  new  nodules 
may  be  detected.  In  some  of  these  cases  violent  neuralgic 
pains  are  present  in  the  gland  (mastodynia).  Chronic  lobular 
mastitis  is  apt  to  lead  to  cyst-formation.  When  cysts  form 
fluid  may  occasionally  discharge  from  the  nipple. 

Treatment. — Support  the  breast  and  apply  ichthyol  oint- 
ment or  belladonna  ointment.  Examine  the  generative  organs 
and  correct  any  existing  abnormality.  Improve  the  general 
health  by  good  food,  tonics,  and  open-air  life.  In  cases 
where  multiple  cysts  are  known  to  exist  the  question  of 
treatment  is  uncertain.  There  seems  to  be  no  doubt  that 
such  cases  tend  in  some  instances  to  eventuate  in  cancer.  We 
believe  that  the  proper  treatment  is  extirpation  of  the  breast. 

Tuberculosis  of  the  Mammary  Gland. — (See  page 
io8.) 

Cysts  and  Tumors  of  the  Nipple  and  the  Mam- 
mary Gland. — Tumors  are  rare  in  the  nipple,  but  do  some- 
times occur.  The  following  growths  are  occasionally  seen : 
fibroma,  angeioma,  papilloma,  myxoma,  myoma,  and  epithe- 
lioma. Sebaceous  cysts  of  the  nipple  and  areola  are  not  very 
unusual.  A  cancer  of  the  nipple  may  be  a  primary  growth,  or 
may  be  secondary  to  gland  cancer.  Primary  epithelioma  of 
the  nipple  presents  the  same  general  characters  as  epithelioma 
in  any  other  region.  It  begins  as  an  indurated  area  in  the 
areola,  or  an  excoriation  of  the  nipple.  Ulceration  soon 
occurs.  The  ulcer  is  irregular  in  outline,  has  hard  edges,  fur- 
nishes a  foul  red  flow,  and  the  discharge  is  sanious  and  fetid. 
The  mammary  gland  becomes  infiltrated  at  an  early  period. 
The  subclavian  glands  enlarge,  and  later  the  axillary  glands. 


DISEASES   OF  THE  BREAST.  863 

This  growth  must  not  be  confounded  with  a  chancre  of  the 
nipple. 

Treatment  of  Tumors  of  the  Nipple. — Innocent  tumors  are 
to  be  excised  and  the  breast  need  not  be  removed. 

EpitheHoma  of  the  nipple  requires  the  complete  extirpa- 
tion of  the  breast,  and  also  the  clearing  out  of  the  lymphatic 
contents  of  the  axilla,  and  possibly  of  the  subclavian  triangle. 

Paget' s  Disease  of  the  Nipple  (Malignant  Derma- 
titis).— This  condition  is  a  chronic  inflammation  of  the 
epithelial  layer  of  the  nipple  and  areola  occurring  in  women 
beyond  middle  life,  and  is  a  not  unusual  precursor  of  epi- 
thelioma of  the  nipple  and  of  duct  cancer.  Paget's  disease 
is  not  a  simple  eczema,  it  is  not  associated  with  the  usual 
causes  and  attendants  of  eczema  either  local  or  constitu- 
tional, and  is  not  cured  by  remedies  which  control  the 
ordinary  disease. 

The  diseased  area  is  raw  and  red,  and  from  it  exudes 
copiously  a  thick,  yellow  discharge.  In  some  cases  Paget's 
disease  is  secondary  to  duct  cancer,  auto-infection  of  the 
nipple  having  been  effected  by  the  fluid  flowing  from  the 
ducts.  Investigations  have  shown  the  presence  of  psoro- 
sperms  in  an  area  of  Paget's  disease. 

Treatment  consists  of  removal  of  the  entire  breast  and 
clearing  out  of  the  axilla  and  subclavian  triangle. 

Tumors  of  the  Mammary  Gland. — These  tumors 
may  be  innocent  or  malignant.     The  innocent  tumors  are 

Fibro-adenomata  or  Cystic  Adenomata,  Myxomata, 
Villous  Papillomata,  and  Angiomata. — It  is  maintained 
by  most  authorities  that  any  innocent  tumor  of  the  gland 
may  and  often   does  become  malignant. 

Pibro-adenoma. — The  nomenclature  of  these  growths 
is  in  a  state  of  great  confusion.  The  name  of  fibro-aden- 
oma  was  given  by  Cornil  and  Ranvier  to  the  same  sort  of 
growth  which  the  younger  Gross  called  a  fibroma,  Billroth 
an  adeno-fibroma,  and  Sir  Astley  Cooper  a  chronic  mam- 
mary tumor.  It  is  doubtful  if  a  pure  fibroma  ev^er  occurs 
in  the  mammarj^  gland  (Senn).  A  fibro-adenoma  consists 
of  acini  surrounded  by  fibrous  tissue.  Each  of  these 
structures  proliferates,  but  the  fibrous  tissue  does  so 
much  more  rapidly  than  the  glandular.  A  growth  of  this 
character  is  surrounded  by  a  capsule,  and  is  moveable.  It 
is  firm,  elastic,  lobulated,  superficially  situated,  and  of  slow 
growth.  It  is  unassociated  with  retracted  nipple,  glandular 
enlargement,  adhesion  to  the  skin,  or  cachexia,  and  may 
occur  at  any  age  up  to  fifty,  but  is  most  common  between 


864  MODERN  SURGERY. 

twenty  and  thirty  (J.  Bland  Sutton).  Such  a  tumor  is  rarely 
very  painful,  but  it  may  be  tender  on  rough  handling  and 
may  be  painful  at  the  menstrual  period.  As  a  rule,  there  is 
but  one  of  these  tumors  in  a  mammary  gland,  but  one  may 
exist  in  each  gland. 

Treatment. — Extirpation  of  the  tumor. 

Cystic  adenoma  (adenocele)  is  a  rare  form  of  slowly- 
growing  tumor,  which  is  apt  to  grow  to  a  large  size,  which 
is  nodular  in  outline,  hard  to  the  touch,  and  firmly  attached 
to  the  breast,  but  mobile  upon  the  chest.  A  cystic  adenoma 
has  a  distinct  capsule.  This  form  of  tumor  is  painless,  and 
is  most  apt  to  occur  in  women  between  thirty  and  forty 
who  have  born  children.  The  growth  is  adherent  to  the 
skin,  but  the  cutaneous  surface  is  not  discolored,  the  cuta- 
neous veins  are  not  distended,  the  axillary  glands  are  not 
enlarged,  and  the  nipple  is  not  retracted.  From  the  walls 
of  the  dilated  acini  papillomatous  growths  are  apt  to  arise 
(intracystic  vegetations). 

Treatment. — Removal  of  the  breast. 

Myxoma  is  a  rare  tumor,  and  only  occurs  in  a  person  of 
middle  age.  The  growth  is  solitary,  is  soft,  may  be  round 
or  lobulated,  and  occasionally  fungates.  The  nipple  is  not 
retracted,  the  superficial  veins  are  not  distended,  and  the 
axillary  glands  are  not  enlarged. 

Treatment. — Removal  of  the  mammary  gland. 

Angioma. — This  form  of  tumor  is  very  rare.  It  may 
arise  secondarily  to  a  nevus  of  the  skin  (Sutton).  The 
diagnosis  of  angioma  of  the  skin  is  readily  made.  In 
a  cavernous  angioma  of  the  breast  it  will  be  found  that 
the  tumor  can  be  lessened  in  size  by  pressure,  and  will  be 
increased  in  size  by  coughing,  laughing,  and  holding  the 
breath.  Pulsation  may  be  detected  and  a  bruit  may  be 
audible. 

Treatment. — For  treatment  of  nevus  see  page  226.  If  a 
cavernous  angioma  exists  in  the  mammary  gland,  it  will  be 
necessary  to  extirpate  the  gland. 

Cysts  of  the  Mammary  Gland. — Involution  cysts 
(cystic  degeneration  of  the  mamma)  occur  in  women 
who  are  approaching  the  menopause.  They  occur  earlier 
in  those  who  are  sterile  than  in  those  who  have  born  chil- 
dren, and  may  arise  after  chronic  mastitis.  The  paren- 
chyma of  the  gland  undergoes  atrophic  change,  but  the 
ducts  remain,  become  blocked  and  dilated.  Numerous 
small  cysts  form,  and  both  glands,  as  a  rule,  suffer.  Villous 
growths  may  arise  in  the  walls  of  the  ducts.     In  some  cases 


DISEASES   OF   THE   BREAST.  865 

there  is  much  white  fibrous  tissue  between  the  cysts  (cystic 
fibroma). 

The  subjects  of  this  disease  are  often  nervous,  hysterical, 
and  despondent.  One  or  more  ill -defined  indurations  are 
detected.  Frequently  there  is  a  history  of  discharge  from 
the  nipple  and  of  attacks  of  lancinating  pain  in  the  breast. 
Cystic  breasts  are  dangerous,  because  the  intracystic  vege- 
tations are  liable  to  eventuate  in  duct  cancer. 

Treatment. — In  such  cases,  after  confirming  the  diagnosis 
by  an  exploratory  incision,  remove  the  entire  breast  (Snow). 

Lacteal  cyst  (galactocele)  is  an  accumulation  of  milk 
brought  about  by  blocking  of  some  of  the  milk-ducts.  It 
arises  soon  after  the  delivery  of  the  child,  and  grows  rapidly. 
A  large  quantity  of  milk  may  collect,  and  rupture  of  the 
cyst-walls  can  occur,  the  fluid  passing  into  the  glandular 
connective  tissue. 

A  galactocele  is  rounded,  fluctuates  distinctly,  and  increases 
in  size  during  nursing.  There  is  little  or  no  pain.  In 
some  cases  the  contents  of  the  cyst  coagulate  and  a  solid 
mass  is  formed. 

Treatment. — Incision  and  drainage. 

Hydatid  cysts  are  rare,  but  do  occasionally  occur. 

Treatment. — Excision. 

Maligfnant  tumors  of  the  mammary  gland  are  ten 
times  more  common  than  innocent  tumors. 

Sarcoma. — Sarcoma  of  the  mammary  gland  is  a  very  rare 
growth  (less  than  10  per  cent,  of  breast  tumors).  It  may  occur 
at  any  age  from  pubert}'  to  old  age,  but  is  most  common  from 
twenty  to  thirty-five.  The  growth  may  be  composed  of  round 
cells  or  spindle  cells,  both  varieties  may  be  present,  and 
myeloid  cells  may  be  found.  Circumscribed  sarcoma  arises 
usually  between  the  ages  of  twenty  and  thirty;  it  is  firm  to  the 
touch,  as  it  contains  much  fibrous  tissue,  is  painless,  does  not 
grow  very  rapidly,  glands  are  not  involved,  and  there  is  no 
cachexia.  The  nipple  is  not  retracted.  The  growth  may 
adhere  to  the  skin.  It  is  composed  of  giant-cells  or  spindle- 
cells,  and  rarely  returns  after  extirpation  of  the  breast. 

Diffused  sarcoma  is  composed  of  small  round  cells, 
arises  in  the  center  of  the  breast,  and  grows  with  great 
rapidity.  It  is  most  commonly  met  with  about  the  age  of 
thirty-five,  and  a  history  of  injury  can  often  be  elicited.  The 
tumor  is  soft,  some  parts  being  softer  than  others  because 
of  cyst-formation.  It  is  usually  mobile  upon  the  thorax, 
though  it  soon  becomes  adherent  to  the  skin.  The  tumor 
reaches  a  very  great  size,  and  soon  fungates  through  the 
55 


866  MODERN  SURGERY. 

skin.  There  is  little  or  no  pain.  The  cutaneous  veins  over 
the  tumor  are  distended,  the  nipple  is  not  retracted,  and  the 
axillary  glands  are  not  often  enlarged.  Diffuse  sarcoma  is 
apt  to  recur  after  removal. 

Treatment. — Remove  the  breast,  and  if  the  muscles  of  the 
chest-wall  are  infiltrated,  remove  them.  The  axillary  glands 
are  removed  if  they  are  enlarged,  but  not  otherwise.  Opera- 
tion will  not  cure  when  metastases  exist.  If  the  case  is  in- 
operable, we  can  try  the  use  of  Coley's  fluid.  If  the  toxins 
of  erysipelas  fail  to  arrest  the  progress  of  the  disease,  keep 
the  patient  as  comfortable  as  possible  by  the  administration 
of  cocain  and  morphin. 

Carcinonia  or  Cancer  of  the  Mammary  G-land. — The 
great  majority  of  mammary  tumors  belong  to  the  genus 
carcinoma.  Cancer  is  due  to  proliferation  of  the  epithelium 
of  the  acini  (acinous  cancer)  or  of  the  ducts  (duct  cancer). 

Acinous  cancer  is  vastly  commoner  than  duct  cancer. 
Usually  there  is  much  connective  tissue  and  but  little 
parenchyma  in  the  growth  (scirrhus  cancer).  In  some 
cases  there  is  little  connective  tissue  and  much  parenchyma 
(encephaloid  or  medullary  cancer).  If  colloid  degeneration 
of  the  parenchyma  or  stroma  occurs,  the  growth  is  spoken 
of  as  colloid  cancer. 

Scirrhus,  the  common  form  of  acinous  cancer,  is  almost  as 
hard  as  stone.  On  section  it  is  concave,  and  Sutton  says 
"  resembles  an  unripe  pear."  The  tumor  is  without  a  cap- 
sule, and  the  epithelial  cells  are  surrounded  by  masses  of 
fibrous  tissue.  Portions  of  tissue,  even  some  distance  away 
from  the  tumor,  contain  foci  of  proliferating  embryonic  epi- 
thelial cells.  In  atrophic  or  withering  scirrhus  the  fibrous 
stroma  contracts  and  epithelial  cells  undergo  fatty  degenera- 
tion (Senn). 

Causes  and  Symptoms. — Scirrhus  is  more  common  among 
women  who  have  born  children  than  among  those  who  have 
not.  Heredity  is  manifest  in  only  about  lo  per  cent,  of  cases 
(Bryant).  The  younger  Gross  found  it  in  one  case  out  of 
nine.  Trauma  has  no  apparent  influence  in  producing  can- 
cer. The  disease  is  rare  before  the  age  of  thirty-five,  and 
is  most  common  between  forty-five  and  fifty.  The  author 
operated  for  scirrhus  of  the  breast  on  a  woman  only 
twenty-seven  years  of  age.  Henry  saw  a  woman  of 
twenty-one  with  cancer.  It  is  frequently  met  with  in 
the  aged.  These  tumors  are  rare  in  the  negro  race. 
A  hard  nodule  is  found  in  the  breast,  usually  under  the 
nipple,  but  possibly  far  away  from  it.     The  growth  is  nod- 


DISEASES   OF   THE   BREAST.  86/ 

ular,  and  is  immobile  from  the  beginning.  In  a  large,  fat 
breast  there  is  often  a  deceptive  sense  of  mobility,  because 
some  of  the  breast-tissue  moves  with  the  tumor.  The  cancer 
may  have  been  present  for  a  considerable  time  before  being 
discovered.  In  obscure  lesions  of  bones  and  viscera  examine 
the  mammar>^  glands,  because  the  trouble  might  be  due  to 
metastasis  from  an  undiscovered  carcinoma  of  the  breast. 
Retraction  of  the  nipple  is  present  in  over  one-half  of  the 
cases  (S.  W.  Gross).  It  occurs  when  the  grow'th  is  near  the 
nipple,  and  is  due  to  the  contracting  fibrous  tissues  of  the 
tumor  pulling  on  the  milk-ducts.  If  the  growth  is  far  away 
from  the  nipple,  a  dimple  is  apt  to  form  on  the  skin  of  the 
breast  because  of  the  pulling  upon  the  suspensory  fibers. 

Glandular  enlargement  in  the  axilla  soon  follows  the  ap- 
pearance of  a  scirrhus  ;  the  glands  become  very  hard  and 
adherent.  In  ov^er  60  per  cent,  of  persons  the  glands  of  the 
axilla  are  felt  to  be  enlarged  when  the  patient  first  comes  for 
treatment.  Because  the  surgeon  cannot  feel  enlarged  glands  is 
no  proof  that  there  are  none.  As  a  matter  of  fact,  the  glands 
are  usually  involved  within  two  months  of  the  beginning  of 
the  disease,  but  the  involvement  can  rarely  be  detected  ex- 
ternally until  months  later.  Enlargement  of  the  axillary 
glands  is  follow^ed  by  enlargement  of  the  glands  in  the  pos- 
terior cervical  triangle  and  in  the  mediastinum.  Herbert 
Snow  has  shown  that  the  blocking  of  the  axillary  glands 
often  leads  to  regurgitation  of  lymph  containing  cancer-cells, 
the  cells  being  thus  deposited  in  the  head  of  the  humerus 
and  the  thymus  gland.  Cells  in  the  thymus,  after  a  time, 
cause  a  projection  of  the  sternum  (the  sternal  symptom). 
When  the  axillary  lymphatics  are  extensively  involved  the 
arm  swells  from  obstruction  to  the  lymph-flow  (lymph 
edema)  or  pressure  upon  the  vein.  The  tumor  usually 
grows  rather  slowly  unless  lactation  is  established,  then  it 
grows  rapidly.  As  it  grows  it  infiltrates  adjacent  structures 
(the  pectoral  fascia,  pectoral  muscles,  subcutaneous  cellular 
tissue,  and  skin).  When  the  skin  is  destroyed  an  ulcer  forms, 
and  around  this  ulcer  the  skin  becomes  red  and  filled  with 
cancerous  nodules,  which  feel  like  shot  in  the  skin.  Metas- 
tases are  apt  to  occur  into  the  bones,  liver,  brain,  pleura, 
spine,  thymus  gland,  and  rarely  the  eye. 

Pain  is  usually  present  in  scirrhus  carcinoma.  It  is  lan- 
cinating and  neuralgic  in  character,  and  not  brought  on  or 
increased  by  handling.  It  ceases  if  colloid  degeneration  be- 
gins. The  general  health  is  usually  unimpaired  until  ulcer- 
ation takes  place,  when  cachexia  arises.     The  cancer  en  cui- 


568  MODERN  SURGERY. 

rassc  of  Velpeau  is  a  condition  in  which  the  lymphatic  vessels 
of  the  skin  are  extensively  invaded,  the  growth  itself  being 
adherent  to  the  wall  of  the  thorax.  In  this  condition  the 
chest-wall  is  fixed,  respiration  is  difficult,  and  the  temperature 
is  commonly  somewhat  elevated. 

In  atrophic  or  withering  scirrJius  the  contraction  is  so 
great  that  it  seems  as  though  the  mammary  gland  had 
been  removed.  The  duration  of  scirrhus,  when  left  to  run 
its  course,  varies,  but  the  disease  generally  produces  death 
■within  two  and  a  half  years.  Occasionally  it  causes  death 
within  a  year.  In  atrophic  scirrhus  the  patient  may  live  for 
many  years. 

Duct  cancer  is  not  a  common  growth.  It  arises  from  the 
duct-walls  in  conditions  of  cystic  degeneration  of  the  mam- 
mary gland.  The  tumor  is  softer  than  the  acinous  growth, 
and  is  not  nodular.  There  is  no  pain,  no  retraction  of  the 
nipple,  no  skin  dimple.  Serous  or  bloody  fluid  may  often  be 
squeezed  from  the  nipple.  A  duct  cancer  grows,  infiltrates 
slowly,  and  involves  adjacent  glands  later  than  does  scirrhus. 

Treatment  of  Carcinoma  of  tJie  Mammary  Gland. — The 
treatment  is  early  and  thorough  operation,  the  earlier  and 
the  more  thorough  the^  better.  The  older  surgeons  oper- 
ated simply  to  prolong  life  a  few  months ;  the  modern 
surgeon  operates  with  the  hope  of  curing  the  patient.  In 
1878,  Billroth's  statistics  showed  only  8  cures  in  143 
cases.  In  1896,  W.  Watson  Cheyne  reported  12  cures  out 
of  21  cases  (57  per  cent.).  The  operation  should  remove 
the  breast  and  much  of  the  skin  above  it,  the  pectoral  fascia, 
and  often  the  pectoral  muscles ;  the  fat  and  glands  of  the 
axilla,  and  sometimes  the  fat  and  glands  of  the  subclavian 
triangle.  If  three  years  after  an  operation  there  has  been  no 
return,  we  regard  the  case  as  cured  (Volkmann's  limit).  Cer- 
tain cases  are  unsuited  for  a  radical  operation  :  cases  in  which 
metastases  exist ;  cases  of  cancer  en  cuirasse ;  cases  where 
axillary  involvement  is  very  great.  Cheyne  would  also  rule 
out  cases  where  large  glands  may  be  felt  above  the  clavicle, 
believing  that  in  such  cases  the  mediastinal  glands  must  be 
cancerous.^ 

Halsted's  Operation. — Halsted  performs  a  very  radical 
operation.  He  removes  suspected  tissue  in  one  piece,  and 
thus  prevents  carcinoma  cells  falling  in  the  wound,  for  it  is 
well  known  that  if  such  cells  should  fall  into  the  wound  they 
may  grow  just  as  may  a  graft  of  healthy  epithelium.  The 
neck,  shoulder,  the  arm  to  the  elbow,  the  entire  surface  of 

1  See  Objects  and  Limits  of  Opej'ations  for  Cancer,  by  W.  Watson  Cheyne. 


DISEASES   OF   THE   BREAST. 


869 


the  chest  down  to  the  waist,  the  breast  itself,  the  axilla,  the 
side  and  the  back  must  be  sterilized.  It  is  necessary  to  have, 
besides  scalpels,  and  the  ordinary  instruments  for  an  opera- 
tion, a  great  number  of  hemostatic  forceps  (80  to  lOo).  Place 
the  patient  recumbent,  with  a  sand-pillow  under  the  shoul- 
der of  the  affected  side.  The  shoulder  is  right  at  the  edge 
of  the  bed,  and  a  nurse  holds  the  arm  from  the  side.  Hal- 
sted  describes  his  operation  as  follows  :  ^  The  skin  incis- 
ion is  made  as  shown  in  Fig.  331,  and  is  carried  at  once 
through  the  fat.     The  triangular  skin  flap  {a,  b,  r,)  is  turned 


'"^C"^^ 


Fig.  331. — Halsted's  operation  for  carcinoma  of  the  breast :  the  first  incision. 

down.  The  costal  insertions  of  the  great  pectoral  muscle 
and  the  muscle  are  split  between  the  clavicular  and  costal 
portions  and  up  to  a  point  on  the  clavicle  opposite  to  the 
scalene  tubercle,  and  at  this  point  the  clavicular  portion  of 
the  muscle  and  the  tissue  overlying  it  are  cut  through  close 
to  the  clavicle,  and  the  apex  of  the  axilla  is  at  once  exposed. 
The  cellular  tissue  under  the  clavicular  portion  of  the  muscle 
is  dissected  from  the  muscle,  and  the  splitting  of  the  muscle 
is  continued  on  to  the  humerus.  The  part  of  the  muscle  to 
be  removed  is  cut  through  close  to  its  humeral  insertion. 
The  whole  mass  circumscribed  by  the  first  incision  (skin, 
breast,  areolar  tissue,  and  fat)  is  raised  with  considerable  force 
in  order  to  put  the  submuscular  fascia  on  the  stretch  as  it  is 
stripped  from  the  thorax  close  to  the  ribs.  It  is  well  to  in- 
clude the  delicate  sheath  of  the  pectoralis  minor  muscle. 
The  lower  and  outer  boundary  of  the  lesser  pectoral  having 

1  Johns  Hopkins  Hasp.  Reports,  vol.  iv. ;  Annals  of  Sitrg.,  Nov.,  1894. 


8/0  MODERN  SURGERY. 

been  passed  and  exposed,  the  muscle  is  cut  at  a  right  angle 
to  its  fibers  and  a  little  below  the  middle.  The  tissue  over 
the  minor  muscle  near  its  coracoid  insertion  is  divided  as  far 
out  as  possible,  and  is  then  reflected  inward  to  prepare  for 
the  reflection  upward  of  this  part  of  the  minor  muscle. 
The  upper  portion  of  the  minor  muscle  is  retracted  upward 
(Fig.  332).  The  small  blood-vessels  under  the  minor  mus- 
cle are  carefully  separated  from  it,  are  dissected   out  very 


^\ 


Fig.  332. — Halsted's  operation  for  carcinoma  of  the  breast  :  the  mass  turned  down. 

clear,  and  are  ligated  close  to  the  axillary  vessels.  Having 
exposed  the  subclavian  vein  at  the  highest  possible  point 
below  the  clavicle,  the  contents  of  the  axilla  are  dissected 
away  with  a  sharp  knife  and  the  vein  and  its  branches  are 
stripped  absolutely  clean.  The  loose  tissue  about  the  artery 
and  the  nerves  should  also  be  removed.  When  the  vessels 
are  cleared  the  axillary  contents  are  rapidly  stripped  from 
the  inner  walls  of  the  axilla  and  the  lateral  wall  of  the 
thorax.  The  fascia  which  binds  the  mass  to  the  chest  is  cut 
close  to  the  ribs  and  the  serratus  magnus  muscle.  Just 
before  reaching  the  junction  of  the  posterior  and  lateral 
walls  of  the  axilla,  an  assistant  draws  the  triangular  flap  of 
skin  outward  in  order  to  spread  out  the  tissue  which  lies 
upon  the  subscapulars,  teres  major,  and  latissimus  dorsi 
muscles.  The  operator  cleans  the  posterior  wall  of  the 
axilla  from  within  outward.  The  subscapular  vessels  are 
clearly  exposed,  and  are  caught  before  they  are  cut.  In  some 
cases  the  subscapular  nerves  are  removed,  in  others  they  are 
permitted  to  remain.     Having  passed  these  nerves  the  mass 


SKIAGRAPHY,  OR  EMPLOYMENT  OF  RONTGEN  RA  YS.    87 1 

is  turned  back  into  its  normal  position  and  severed  from 
the  body  of  the  patient  by  a  stroke  of  the  knife  from  b 
to  c,  repeating  the  first  cut  through  the  skin.  Every  bleed- 
ing point,  however  small,  is  tied  with  fine  silk,  from  60  to 
100  ligatures,  or  even  more,  may  be  required. 

After  the  completion  of  the  operation  the  wound  into  the 
axilla  is  closed  with  a  subcuticular  stitch  of  silver  wire ;  if  a  cut 
has  been  carried  above  the  clavicle,  it  is  closed  in  the  same  man- 
ner, and  the  edges  of  the  elliptical  opening  are  brought  nearer 
together  by  a  purse-string  subcuticular  stitch.  Thiersch  grafts 
cut  from  the  patient's  thigh  are  used  to  cover  the  gap.  Silver 
foil  is  placed  over  the  wound,  this  is  covered  with  gauze, 
bandages  are  applied,  and  the  dressing  is  overlaid  by  a  plas- 
ter-of-Paris  bandage,  which  includes  the  head,  neck,  chest, 
and  arm.  The  area  from  which  grafts  were  taken  is  dressed 
with  sterile  gauze  or  an  ointment  containing  boric  acid. 

XXXIX.  SKIAGRAPHY,  OR  THE  EMPLOYMENT  OF 
THE  RONTGEN  RAYS. 

The  cathode  rays  were  discovered  by  Hittorf,  in  1869, 
while  passing  an  induction  current  through  a  vacuum-tube. 
Crookes  of  London  greatly  improved  the  vacuum-tube,  and 
obtained  a  rarefaction  which  left  in  the  tube  but  the  one- 
millionth  of  an  atmosphere.  This  last-named  observer  found 
that  when  an  interrupted  current  of  high  potential  is  passed 
through  a  vacuum  which  is  nearly  perfect,  fluorescence  takes 
place.  In  a  Crookes  tube  the  positive  electrode  is  placed  at 
some  indifferent  point,  and  the  current  from  the  negative  elec- 
trode flows  not  to  the  positive,  but  directly  to  the  wall  of  the 
tube  opposite  the  cathode,  and  at  this  point  the  phospho- 
rescent glow  is  detected. 

In  1895,  Rontgen  of  Wiarzburg,  while  making  a  study  of 
cathode  rays  as  developed  in  Crookes's  tubes,  discovered 
the  energy  which  he  named  the  A'-rays.  Rontgen  showed 
that  at  the  wall  of  the  Crookes  tube  opposite  the  nega- 
tive electrode  a  new  and  hitherto  unknown  energy  is  gen- 
erated. Because  of  the  uncertain  character  of  this  energy 
he  gave  to  its  manifestation  the  name  of  the  X  or  unknown 
rays. 

The  A'-rays  are  invisible  ;  cannot  be  deflected,  reflected, 
refracted,  or  concentrated ;  are  not  influenced  by  the  mag- 
net ;  and  produce  none  of  the  ordinarily  recognized  effects 
of  heat.  They  cause  fluorescence  in  certain  substances, 
notably  in  tungstate  of  calcium  (Edison),  platinocyanid  of 


872  MODERN  SURGERY. 

barium  (Rontgen),  and  platinocyanid  of  potassium.  They 
have  a  marvellous  power  of  penetration,  and  pass  through 
many  substances  which  are  opaque  to  sunlight,  ultraviolet 
light,  and  ordinary  electric  light.  They  are  readily  trans- 
mitted by  water,  organic  substances,  leather,  cloth,  paper, 
and  flesh.  Bone  transmits  them  less  easily,  and  metal 
still  less  easily,  but  no  substance  absolutely  prevents  their 
transmission.  An  ordinary  dry  photographic  plate  is 
sensitive  to  the  rays.  If  the  rays  are  intercepted  by  a 
body  not  readily  permeable  which  is  placed  between  the 
Crookes  tube  and  the  photographic  plate,  a  shadow  will  be 
cast,  and  a  picture  of  this  shadow  will  be  formed  upon  the 
plate.  Such  a  picture  is  known  as  a  skiagraph  or  radio- 
graph. If  a  body  more  or  less  resistant  to  the  rays  is  placed 
between  the  tube  and  a  fluorescent  screen,  the  body  casts  a 
shadow  on  the  screen,  and  the  portion  of  the  screen  free 
from  shadow  glows  with  fluorescence.  Such  a  screen  is 
known  as  a  fluoroscope.  It  will  thus  be  seen  that  the  X- 
rays  enable  the  surgeon  to  look  beneath  the  skin  and  to  see 
those  things  which  before  the  discovery  of  Rontgen  were 
unseeable  during  life.^ 

The  real  nature  of  the  X-rays  is  unknown.  They  are  not 
heat-rays ;  they  are  not  ultraviolet  rays.  Rontgen  thinks 
they  are  longitudinal  ether-waves.  Monell  says,  "  They 
appear  to  be  originated  at  the  site  of  the  greatest  electrical 
activity  within  the  tube,  and  their  real  nature  is  as  unknown 
as  the  nature  of  heat,  gravity,  electricity,  mind,  and  of  life 
itself" 

To  obtain  the  rays  a  good  apparatus  is  essential.  An 
ordinary  medical  battery  is  incapable  of  producing  them,  as 
it  is  absolutely  necessary  to  have  a  current  of  high  tension. 
The  discoverer  used  a  Ruhmkorff  coil,  but  this  is  by  no  means 
the  most  satisfactory  apparatus  to  employ.  Some  experi- 
menters have  made  use  of  a  "  powerful  static  machine  and 
transformer  coils"  (Monell).  Swinton  uses  twelve  half-gallon 
Leyden  jars  and  discharges  them  through  the  primary  coil, 
the  secondary  circuit  being  a  Tesla  oil  coil. 

The  current  is  best  taken  from  the  street-light  circuit. 
Monell  says  that  this  current  should  be  controlled  by  an 
interrupter,  the  interruptions  of  which  are  100  per  second. 
The  interrupted  current  is  to  be  passed  into  an  induction  coil, 
and  the  secondary  current  is  to  be  conveyed  into  the  Crookes 

^  See  Rontgen's  report  to  the  Physico-Medical  Society  of  Wiirzburg,  Dec, 
1895  '1  ^'so  t^s  article  upon  the  X-rays  by  S.  H.  Monell,  in  the  Brooklyn  Medical 
Journal,  May,  1896. 


SKIAGRAPHY,  OR  EMPLOYMENT  OF  RONTGEN  RA  YS.    873 

tube  by  two  wires.  The  secondary  current  thus  produced 
will  furnish  a  spark  five  or  six  inches  long. 

When  the  surgeon  is  about  to  use  the  .\-rays,  he  must  re- 
move from  the  person  of  the  individual  anything  that  might 
cause  confusion  or  lead  to  error.  If  the  foot  is  to  be  exam- 
ined, remove  the  shoes,  because  shoes  contain  nails ;  if  the 
hand  is  to  be  examined,  remove  the  gloves  if  they  are  fast- 
ened with  buttons  of  bone  or  metal ;  if  the  thigh  is  to  be 
examined,  remove  coins,  keys,  knives,  etc.,  from  the  pocket ; 
a  garter,  if  it  has  a  metal  clasp,  should  be  taken  off. 

In  order  to  get  the  best  results  from  the  Rontgen  rays,  not 
only  must  the  apparatus  be  good,  but  the  man  who  uses  it 
must  be  expert.  Pictures  taken  by  an  unskilled  man  lack 
clearness  of  outline,  and  may  even  lead  to  positively  erro- 
neous conclusions.  Nevertheless,  a  person  used  to  the  em- 
ployment of  scientific  apparatus  can  very  soon  become  suffi- 
ciently expert  to  take  fairly  clear  pictures  which  should  not 
lead  to  error.  Morris  H.  Richardson^  maintains  that  the 
Rontgen  rays  can  be  employed  successfully  in  the  routine 
office  practice  of  a  general  practitioner. 

The  surgeon  may  utilize  the  A'- rays  by  means  of  a  fluoro- 
scope.  P^dison's  fluoroscope  consists  of  four  sides  of  a 
box,  one  end  being  open  and  made  to  fit  tightly  over 
the  observer's  eyes,  the  other  end  being  closed  with 
cardboard  made  fluorescent  by  smearing  it  with  mucilage, 
and,  before  the  mucilage  is  quite  dry,  sprinkling  it  with 
crystals  of  tungstate  of  calcium.  If  it  is  desired  to  examine 
the  hand  with  a  fluoroscope,  the  extremity  is  held  opposite 
an  excited  Crookes  tube  and  from  six  to  ten  inches  away 
from  it,  the  end  of  the  fluoroscope  which  is  covered  with 
fluorescent  paper  is  placed  near  the  surface  of  the  hand 
which  is  away  from  the  tube,  and  the  observer  looks  through 
the  other  end  of  the  instrument.  The  flesh  seems  but  a  dim 
haze  and  the  shadows  of  the  bones  are  distinctly  outlined. 
The  fluoroscope  can  be  easily  used,  and  gives  reliable  results 
in  studies  upon  the  hands  and  feet,  but  when  deeper  struct- 
ures are  to  be  investigated,  or  when  absolute  accuracy  is 
essential,  it  is  better  to  take  a  skiagraph.  The  value  of 
fluoroscopy  is  constantly  increasing  as  better  electrical  appli- 
ances and  Crookes's  tubes  are  being  made. 

If  thick  tissues  require  to  be  penetrated  by  the  rays,  if 
great  accuracy  is  necessary,  or  if  a  permanent  record  is  to 
be  retained,  a  skiagraph  must  be  taken.  In  taking  these 
pictures   dry  plates  can  be  used ;  the  plate  need  not  be  re- 

'  Medical  News,  Dec,  1S96. 


874  MODERN  SURGERY. 

moved  from  its  wooden  case  during  the  process,  and  it  is  not 
necessary  to  conduct  the  proceeding  in  a  dark  room.  The 
tube  should  be  from  twelve  to  fifteen  inches  away  from  the 
surface  of  the  body.  The  plate  must  be  fastened  to  the 
surface  exactly  opposite  the  tube.  It  is  necess-ary  to  ob- 
serve care  in  the  adjustment  of  the  plate,  because  the  X- 
rays  travel  only  in  straight  lines,  and  any  carelessness  of 
adjustment  will  lead  to  curious  and  misleading  aberration 
in  the  picture.  The  length  of  exposure  necessary  varies 
with  the  thickness  of  the  tissues,  the  structure  of  the 
part,  the  nature  of  the  body  we  wish  a  picture  of,  and  the 
perfection  of  the  apparatus,  from  three  minutes  to  one  hour. 
Prolonged  exposure  is  undesirable  if  it  can  be  avoided,  as  it 
may  produce  an  JT-ray  "  burn." 

The  so-called  X-ray  "  burn"  is  not  a  burn  at  all.  A  burn 
is  due  to  the  contact  of  heat,  is  accompanied  with  pain 
from  the  moment  of  application,  and  is  followed  by  inflam- 
matory changes,  beginning  on  the  surface.  An  JT-ray  "burn" 
is  not  manifest  for  several  days  or  even  several  weeks  after 
the  application  of  the  rays,  at  which  period  an  inflammatory 
or  a  gangrenous  process  arises,  which  begins  within  the 
tissues  and  subsequently  involves  the  surface.^  These  burns 
are  often  accompanied  by  loss  of  hair  or  nails  in  the  damaged 
area,  they  require  months  to  heal,  if  they  heal  at  all,  are  very 
painful,  and  are  not  improved  by  treatment  which  relieves  ordi- 
nary burns.  In  some  cases  the  consequences  are  very  serious. 
In  a  case  reported  by  J.  P.  Tuttle,  it  became  necessary  to  ampu- 
tate the  thigh."  The  lesions  occasionally  produced  by  the 
X-rays  are  probably  trophic  changes.  Sections  made  by 
Vissman  from  Tuttle's  case  indicated  that  the  lesion  was  a 
gangrenous  process  due  to  arteritis  of  the  smaller  vessels. 
These  A''- ray  injuries  are  most  liable  to  occur  when  a 
Ruhmkorff  coil  is  used,  and  no  such  condition  has  been 
caused  by  a  static  machine  (Tuttle).  It  has  been  suggested 
that  a  thin  piece  of  aluminum  placed  upon  the  part  while 
it  is  exposed  to  the  A'-rays  will  prevent  the  occurrence  of 
these  injuries.  Skin-grafting  may  succeed  in  remedying  an 
ulceration,  but,  as  a  rule,  the  grafts  do  not  grow,  or  if  they 
adhere,  are  very  apt  to  break  down  after  a  time.  In  many 
cases  the  best  treatment  is  excision  (Powell). 

The  uses  of  the  A-rays  are  legion.  They  are  of  the 
greatest  possible  value  in  the  location  of  foreign  bodies, 
especially  bodies  of  metal,  glass,  or  bone,  such  as  bullets, 

1  E.  B.  Bronson,  in  the  debate  on  J.  P.  Tuttle's  case,  Medical  Record,  March 
5,  189S.  ^  Med.  Record,  May  5,  1898. 


RONTGEN   RAYS. 


Plate  7. 


^2  3 

1.  Gunshot-wound  of  the  Lung.  Rib-resection  for  secondary  hemorrhage  into  the 
pleural  sac  ten  days  after  the  injury;  bullet  not  removed.  Hemorrhage  arrested  by  pack- 
ing with  gauze.    Skiagraph  taken  three  months  afterward  shows  the  bullet.     (Author's  case  ) 

2.  Fracture  of  Lower  End  of  the  Femur.  Reduction  of  fragments  impossible  because 
of  the  liiicrposition  of  a  loose  piece  of  bone  and  much  muscle  between  fragments  (Author's 
case.) 

3.  Case  shown  in  Figure  2,  Three  Months  after  the  Operation  of  Wiring.  Nine  months 
after  operation,  the  man  is  walking  about  with  ease,  and  the  wire  is  still  in  place. 

(The  above  skiagraphs  are  from  the  A'-Ray  Laboratory  of  the  jtjfferson  Medical  College 
Hospital.) 


SKI  A  GRA  PH  W  OR  EMPL  O  YMENT  OF  R  ONTGEN  RA  I  '.9.    875 

and  needles,  glass,  splinters,  etc.  Bullets  are  readily  de- 
tected in  the  extremities ;  have  been  found  in  the  lun<,r- 
substance  and  bronchi  (Rowland),  in  the  brain  (Schier,  Bris- 
saud  and  Londe,  Henchen  and  Sennauer,  Bruce,  Willy 
Meyer),  in  the  abdomen,  the  pelvis,  a  joint,  the  spine,  and 
the  eye.  The  A'-rays  will  enable  us  after  an  abdominal 
operation  to  locate  a  Murphy  button  and  tell  when  it  has 
loosened    and    descended.       Foreign    bodies,    especially    if 


Fig.  333. — W.  M.  Sweet's  A'-ray  apparatus  for  locating  foreign  bodies. 

metallic,  in  the  esophagus,  stomach,  intestine,  and  air-pas- 
sages ;  enteroliths,  and  mineral  calculi  in  the  salivary  ducts, 
bladder,  ureter,  and  kidney,  can  be  detected.  Henry  Morris 
tells  us  that  a  calculus  in  the  kidney  may  exist  and  yet 
escape  detection  with  the  rays,  because  the  kidney  is  very 
deeply  placed,  is  under  the  ribs  and  close  to  the  verte- 
bral column.  Occasionally  a  drainage-tube  lost  in  the  pleural 
sac  may  be  discovered.  Gall-stones  cannot  be  discerned. 
The  rays  may  fail  to  disclose  a  foreign  body  because  of  its 
being  overshadowed  by  a  bone(Carless),  but  prolonged  expos- 


?,76 


MODERN  SURGERY. 


ure  or  the  taking  of  another  picture  with  the  part  in  another 
position  will  bring  it  into  view.  In  many  cases  a  skiagraph 
does  not  indicate  how  deeply  in  the  tissues  a  foreign  body 
lies,  or  upon  which  side  of  a  bone  it  is  lodged.^  If  there  is 
doubt,  take  several  pictures  from  different  positions  (tri- 
angulation),  skiagraph  over  a  surface  marked  in  squares, 
insert  guide-needles  into  the  tissues  before  taking  the  final 
picture,  or  employ  Sweet's  apparatus.  Sweet's  apparatus 
has  been  used  successfully  for  the  location  of  foreign  bodies 
in  the  eye,  but  a  modification  of  the  original  apparatus 
has  recently  been  used  to  skiagraph  other  regions  of  the 
body.  Fig.  333  shows  this  apparatus.  The  negative  ex- 
hibits the  pointers,  and  the  position  of  the  foreign  body  can 
be  determined  by  the  use  of  projection-Hnes  (Figs.  334,  335). 
In  detecting  fractures  and  dislocations  the  Rontgen  rays  are 
of  great  value,  especially  when  there  is  much  swelling,  when 
there  is  little  displacement,  and  when  the  fracture  is  in 
or  about  a  joint.  The  rays  enable  us  to  determine  the 
nature  of  the  injury,  the  amount  of  splintering,  the  exist- 


■O. 


Fig.  334. — Outlines  of  negative  taken  by  Sweet's  method. 

ence  of  impaction,  the  question  whether  or  not  the  frag- 
ments are  in  contact  or  can  be  brought  into  contact ;  the 
direction  of  the  line  of  fracture,  the  variety  of  deformity, 
the  existence  of  more  than  one  fracture,  the  presence  of 
epiphyseal  separation  or  dislocation  alone  or  with  a  fracture, 

1  Battle's  case  in  Lancet,  Feb.  29,  1896. 


SKIAGRAPHY,  OR  EMPLOYMENT  OE  RONTGEN  RA  YS.    877 

the  existence  of  an  ununited  fracture,  and  the  question  if  the 
sphnts  are  holding  the  fragments  in  accurate  apposition. 
Fractures  of  the  skull,  if  in\'olving  both  tables  of  the  vault, 
may  be  recognized ;  it  is  possible  that  fractures  of  the  inner 
table  may  be  found ;  fractures  of  the  base  can  be  seen,  but 
with  difficulty  (White).  Fractures  of  the  spine  never  show 
very  clearly.  To  take  a  picture  of  a  fractured  rib,  first  limit 
chest-motion  by  bandaging  (White).      Morris  tells  us  to  be 


Fig.  335. — Sweet's  projection-lines  for  locating  foreign  bodies  in  the  eye:  a,  transverse 
section  ;  b,  vertical  section.  The  same  principle  is  used  in  locating  foreign  bodies  in  other 
structures. 


somewhat  skeptical  in  accepting  unreservedly  the  evidence 
offered  by  a  skiagraph,  as  slight  carelessness  in  taking  the 
picture  may  mean  great  distortion  and  consequent  error.  The 
A'-rays  ma}'  be  of  value  in  enabling  the  surgeon  to  recognize 
rheumatoid  arthritis  ;  bone-  and  joint-tuberculosis  (the  tuber- 
cular area  being  lighter  than  the  sound  bone) ;  the  amount  of 
acetabular  rim  present  in  congenital  dislocation  of  the  hip-joint 


8/8  MODERN  SURGERY. 

(Rowland) ;  the  state  of  the  bones  in  a  crushed  Hmb  (J.  Hall 
Edwards) ;  bone  deformity ;  osseous  tumors  ;  bone  displace- 
ment (as  in  Morton's  foot) ;  osteomyelitis  ;  caries  ;  necrosis  ; 
and  osteosarcoma.  By  skiagraphy  we  are  enabled  to  decide  on 
the  proper  situation  to  perform  osteotomy,  and  if  a  deformity 
of  the  foot  can  be  amended  without  operation  (Willard). 
The  position  of  the  fetus  in  utero  can  be  definitely  made  out. 
Applied  to  the  soft  parts,  the  new  process  has  obtained 
interesting  but  not  as  yet  many  practically  useful  results. 
Fibrous  tumors  can  be  seen,  but  malignant  tumors,  unless 
they  contain  calcareous  or  fibrous  elements,  cannot  be  defi- 
nitely made  out ;  loose  bodies  in  a  joint  can  often  be  detected. 
The  shadow  of  the  heart  can  be  made  out,  and  the  outlines 
of  the  diaphragm,  kidney,  and  liver  can  be  thrown  upon  the 
screen.  If  the  stomach  is  distended  with  gas,  it  shows  as  a 
light  area  upon  a  dark  background  (Hedley).  If  food  is 
eaten  after  being  mixed  with  subnitrate  of  bismuth,  the  out- 
line of  the  viscus  becomes  fairly  distinct.  Thickened  pleura, 
pleural  effusion,  pulmonary  consolidation,  pericardial  effu- 
sion, aortic  aneurysm;  cavities  in  the  lungs,  and  atheromatous 
blood-vessels  may  be  made  out  with  more  or  less  distinctness. 
If  a  sinus  is  injected  with  iodoform  emulsion,  a  picture  of  it 
can  be  taken,  because  the  emulsion  casts  a  shadow  when 
placed  in  the  path  of  the  X-rays  (J.  Hall  Edwards).  Up  to 
the  present  time  no  positive  evidence  has  been  offered  to 
prove  that  the  Rontgen  force  is  possessed  of  any  therapeutic 
value. 

XL.  INJURIES  BY  ELECTRICITY. 

Bffects  Produced  by  I/ightning. — An  individual  may 
be  struck  directly,  or  he  may  be  shocked  by  an  induced  cur- 
rent, the  lightning  having  struck  a  nearby  object.  A  person 
can  be  struck  while  in  a  room,  but  there  is  more  danger 
when  exposed  especially  in  the  open  country.  To  be 
under  a  single  tree  during  a  thunderstorm  is  dangerous, 
but  to  be  in  a  wood  or  under  a  hedge  is  reasonably  safe. 
The  victim  of  lightning  may  be  killed  instantly.  Death 
is  the  fate  of  over  one  third  of  those  struck.  Tidy  states 
that  out  of  54  cases,  21  died  and  33  recovered.  Post- 
mortem examination  may  fail  to  reveal  a  lesion,  but  in 
many  cases  severe  burns  are  discovered ;  in  some  there  are 
laceration  of  tissue,  crushing  of  bones,  and  fearful  injury. 
Burns  are  especially  apt  to  occur  at  the  points  where  the 
current    entered    and    emerged.      The    clothes    are    usually 


/iVJURIES  BY  ELECTRICITY.  879 

singed  and  torn.  The  typical  lightning-marks  are  arborescent 
tracings,  representing  the  course  of  blood-vessels,  produced 
by  disorganization  and  effusion  of  blood  as  the  fluid  travels 
through  it.  Occasionally  metal  objects,  such  as  buttons, 
knives,  money,  keys,  etc.,  are  fused,  and  spread  as  a  metallic 
film  over  a  considerable  portion  of  the  surface  of  the  body. 
Bichat  stated  that  in  death  from  lightning  rigor  mortis  does 
not  occur.  This  statement  is  now  known  to  be  an  error  (see 
the  three  cases  reported  by  M.  Tourdes).  As  a  rule,  there 
is  early  vigor  mortis,  retained  fluidity  of  blood,  and  disten- 
tion of  the  brain  with  venous  blood.  The  cause  of  death  by 
lightning  was  supposed  by  Hunter  to  be  due  to  destruction 
of  muscular  contractility,  and  by  Richardson  to  the  resolu- 
tion of  the  blood  into  gases.  It  seems  probable  that  some 
deaths  are  due  to  actual  disorganization  of  vital  structure 
and  that  others  are  due  to  shock  or  inhibition.  In  many 
cases  struck  by  lightning  recovery  will  take  place  even  when 
the  individual  is  apparently  dead.  Sestier  reported  yj  cases 
struck  by  lightning,  and  in  7  of  them  the  persons  were 
apparently  dead  for  a  number  of  hours. ^  Brouardel  says  in 
such  cases  the  death-like  state  may  be  ascribed  to  inhibition, 
caused  by  a  inaxiniuin  degree  of  stimulus.^  When  death 
from  lightning  is  not  immediate  the  condition  may  be  as  above 
outlined,  the  individual  being  apparently  dead,  without  ob- 
vious respiration  or  pulse.  He  may  be  insensible,  with  slow 
and  labored  respiration,  a  weak  and  irregular  pulse,  and 
dilated  pupils,  and  may  remain  in  this  condition  for  a  few 
minutes  or  for  several  hours.  The  above  condition  is  not  to 
be  distinguished  from  severe  concussion  of  the  brain.  Every 
individual  suffering  from  the  effects  of  lightning  should  have 
his  entire  body  carefully  examined  to  see  if  physical  injuries 
exist  (fractures,  wounds,  burns,  ecchymoses,  arborescent 
tracings).  The  consequences  of  lightning-stroke  are  many 
and  various.  There  may  be  rapid  and  complete  recovery, 
gradual  recovery,  traimiatic  neurasthenia,  sloughing  burns, 
partial  paralysis,  which  is  usually  recovered  from  (Noth- 
nagel),  but  which  may  be  permanent,  hysteria,  blindness, 
change  of  character,  and  actual  insanity. 

Treatment. — Do  not  pronounce  a  person  dead  until  a  thor- 
ough attempt  at  resuscitation  has  been  made.  Do  not  give 
alcoholic  stimulants.    If  the  respiration  is  feeble  and  apparently 

^  Sestier,  De  la  Eotidre,  Paris,  1866.  Quoted  by  Brouardel  in  his  lectures 
upon  "Death  and  Sudden  Death.'' 

'  Benham's  translation  of  Brouardel's  lectures  upon  "  Death  and  Sudden 
Death." 


88o  MODERN  SURGERY. 

absent,  make  tongue  traction  and  artificial  respiration.  Apply 
the  stream  of  a  cold  douche  to  the  head,  rub  the  limbs  with 
mustard,  put  a  mustard  plaster  over  the  heart  and  another  to 
the  back  of  the  neck,  wrap  the  individual  in  hot  blankets, 
and  give  enemata  of  hot  saline  fluid.  In  some  cases  venesec- 
tion has  seemed  to  be  of  benefit.  When  the  individual  reacts 
treat  any  existing  condition  symptomatically,  and  treat  par- 
ticular physical  injuries  according  to  their  character. 

Kffects  of  Artificial  Currents. — Workmen  for  electric 
companies ;  pedestrians  in  the  streets  of  a  city  which  is 
lighted  by  electricity  or  in  which  trolley  cars  are  em- 
ployed; roofers  and  firemen  are  liable  to  be  injured  by 
electricity.  An  alternating  current  is  decidedly  more 
dangerous  than  a  continuous  current  of  equal  strength. 
An  artificial  current  acts  like  lightning.  It  may  produce 
instant  death  ;  it  may  produce  unconsciousness,  delirium,  ster- 
torous respiration,  Cheyne-Stokes'  breathing,  or  clonic  spasms. 
Its  effects  can  be  often  recovered  from.  Not  unusually  the 
victim  is  apparently  dead,  but  subsequently  recovers.  D'Ar- 
sonval  reports  the  case  of  a  man  who  was  apparently  killed 
by  the  passage  of  4500  volts.  No  attempt  at  resuscitation  was 
made  for  one-half  an  hour,  and  yet  he  recovered  when  artificial 
respiration  was  employed.  Donnellan  reports  a  case  of  re- 
covery after  the  passage  of  1000  volts.  Slight  shocks  may 
cause  temporary  numbness,  and  even  motor  paralysis.  An 
electric  shock  frequently  causes  burns  or  ecchymoses,  and  oc- 
casionally wounds.  Wounds  caused  by  electricity  bleed  pro- 
fusely and  are  apt  to  slough.  An  electric  burn  looks  like  a 
blackened  crust ;  it  is  surrounded  by  pale  skin,  and  for  twenty- 
four  hours  remains  dry,  when  inflammatory  oozing  begins  and 
the  skin  around  it  reddens.  These  burns  are  not  as  painful  as 
are  ordinary  burns,  but  recovery  requires  a  long  time.  When 
inflammation  begins  and  suppuration  occurs,  tissue  is  exten- 
sively destroyed,  tendons,  bones,  and  joints  may  suffer,  some 
portions  become  deeply  excavated,  and  other  portions  show 
dry  adherent  masses  of  dead  and  dying  tissue,  and  a  burn 
which  was  at  first  small  may  be  followed  by  a  large  area  of 
moist  gangrene ;  ^  lack  of  tissue-resistance,  due  to  trophic  dis- 
turbance, is  largely  responsible  for  the  progress  of  the  slough- 
ing. 

Treatment. — If  a  person  is  in  contact  with  a  live  wire,  the 
first  thing  to  do  is,  if  possible,  to  shut  off  the  current.  If  it 
is  not  possible  to  shut  off  the  current,  catch  a  portion  of  the 

^  See  the  article  by  N.  W.  Sharpe  on  "  Peculiarities  and  Treatment  of  Electrical 
Injuries,"  in  Phila.  Med.  Jour.,  Jan.  29,  1898. 


INJURIES  BY  ELECTRICITY.  88 1 

clothing  of  the  victim  and  pull  him  away  from  the  wire, 
but  do  not  touch  his  body  with  a  bare  hand.  If  a  pair  of 
rubber  gloves  can  be  obtained,  the  subject  can  be  moved 
with  impunity  and  the  wires  can  be  safely  cut.  If  it  is  not 
possible  to  drag  a  person  away  from  electric  wires,  the  sur- 
geon can  wrap  his  hands  in  dry  cloth  and  lift  the  portion 
of  the  body  in  contact  with  earth  or  wire,  and  thus  break  the 
circuit  and  permit  of  removal  of  the  bod}'.'  A  dry  cloth  can 
be  pushed  between  the  body  and  the  ground,  and  the  body 
can  then  be  removed  from  the  wires.  It  may  be  possible  to 
push  the  wires  away  by  means  of  a  dry  piece  of  wood,  or  to 
cut  them  with  shears  which  have  wooden  handles  and  which 
are  perfectly  dry.  Treat  the  general  condition  in  the  manner 
set  forth  in  the  article  on  lightning-stroke  (page  879).  Very 
severe  burns  may  be  caused.  The  author  has  dressed  a  num- 
ber of  electric  burns  with  hot  fomentations  of  salt  solution 
during  the  first  few  days.  This  facilitates  the  separation  of 
the  sloughs  and  seems  to  aid  the  weakened  tissues  in  resist- 
ing microbic  invasion ;  after  sloughs  separate,  the  part  is 
dressed  with  dry  sterile  gauze.  Antiseptic  dressings  can  be 
used  from  the  beginning,  but  they  often  fail  entirely  to  arrest 
the  sloughing.  Iodoform  produces  much  irritation.  Ointments 
are  very  unsatisfactory.  When  the  dressings  are  changed  the 
part  should  not  be  washed  with  corrosive  sublimate,  as  this 
agent  produces  much  irritation  ;  peroxid  of  hydrogen  should 
be  employed,  followed  by  hot  normal  salt  solution.  Sharpe 
removes  sloughs  by  applying  the  following  mixture :  2  parts 
of  scale  pepsin,  i  part  of  hydrochloric  acid,  U.S.P. ;  120 
parts  of  distilled  water.  This  mixture  is  washed  off  after 
two  hours  with  peroxid  of  hydrogen.  The  same  surgeon 
treats  necrosis  of  bone  by  injecting  every  few  hours  a  3  per 
cent,  solution  of  hydrochloric  acid,  using  every  second  day 
the  pepsin  solution,  and  when  necrotic  areas  come  away 
packing  with  gauze.  Skin-grafting  by  Reverdin's  method 
or  Thiersch's  method  is  rarely  successful.  In  some  regions  it 
is  possible  to  slide  a  large  flap  in  place  to  cover  a  granulat- 
ing area  which  will  not  heal.  In  a  very  severe  case  amputa- 
tion or  resection  may  be  necessary. 

^  See  the  directions  in  Aled.  Record,  Dec.  28,  1895,  from  Med.  Press. 


56 


INDEX. 


Abbe's  catgut  rings  in  intestinal  anastomosis, 
689 
method  of  intestinal  anastomosis,  690 
operation  for  stricture  of  esophagus,  623 
string  saw,  639 
Abdomen,  diseases  and  injuries  of,  626 

operations  upon,  666 
Abdominal  hernia,  699 
nephrectomy,  782 
section,  666 

for  appendicitis,  668 
wall,  contusions  of,  626 

gunshot-wounds  of,  632 

penetrating  wounds  of,  632 

wounds  of,  632 
Abernethy's  extraperitoneal  method  of  ligat- 

ing  external  iliac  artery,  306 
Abscess,  acute,  96 

symptoms  of,  99 
appendicinal  or  appendicular,  100 

treatment  of,  103 
Bezold's,  563 
Brodie's,  312 
cerebral,  560 
cold,  105,  106 

of  lymphatic  glands,  108 
diagnosis  of,  102 
diffused,  98 
dorsal,  107 
extradural,  560,  564 
forms  of,  98 
healing  of^  87 
iliac,  107 

intramammary,  861 
ischiorectal,  721 
large  cold,  109 
lumbar,  107 
lymphatic,  98 
mediastinal,  loi 
metastatic,  99 
of  antrum  of  Highmore,  loi,  596 

treatment  of,  103 
of  bone,  312 

chronic,  xo8 
of  brain,  100,  560 

symptoms  of,  561 

treatment  of,  103,  562 
of  breast,  101,  860 

acute,  861 

chronic,  108 

treatment  of,  103 
of  cerebellum,  577 
of  frontal  sinus,  597 
of  hip,  414 
of  kidney,  774 
of  larynx,  loi 
of  liver,  100,  660 

treatment  of,  102 
of  lung,  loi,  607 

pneumotomy  for,  611 

treatment  of,  103 
of  lymphatic  glands,  loB 
of  mammary  gland,  cold,  109 
of  maxillary  antrum,  596 


Abscess  of  mediastinum,  loi 
treatment  of,  103 

of  prostate  from  gonorrhea,   treatment  of, 
821 

of  scalp,  540 

of  spleen,  665 

of  temporosphenoidal  lobe,  576 

opening  of,  104 

Paget's,  99 

palmar,  loi,  511 

perinephric,  loi,  776 

perinephritic,  loi    776 

postpharyngeal,  107 

prognosis  of,  102 

prostatic,  loi 

psoas,  107,  109 

residual,  99 

rest  in,  63 

retromammary,  861 

retropharyngeal,  107 

scrofulous,  98 

shirt-stud,  105 

subdural,  560 

subphrenic,  100,  657 

treatment  of,  102 

tubercular,  105 

varieties  of,  98 
Acetanilid,  28 

as  a  drying-powder,  i66 
AchiUodynia,  219 
Acid,  carbolic,  as  an  antiseptic,  25 
Acquired  syphilis,  185 
Acromegaly,  320 
Actinomyces,  183 
Actinomycosis,  18,  183 

cutaneous,  183 

of  bone,  194,  309 

treatment  of,  184 
"Active  clot,"  247 
Active  hyperemia,  48 
Actol,  29 
Acupressure  in  hemorrhage,  262 

in  secondary   hemorrhage   from   atheroma- 
tous vessels,  273 

in  treatment  of  aneurysm,  255 

in  varix,  243 
Acute  abscess,  96,  98 
symptoms  of,  99 

rheumatism,  425 

tetanus,  144 
Adamciewicz  on  cancer-cells,  211 
Adams's  operation,  477 

saw,  475,  476 
Adenitis,  tubercular,  154 
Adenocele  of  mammary  gland,  864 
Adenoid  cancer,  236 
Adenomata,  232 

cystic,  of  mammary  gland,  864 

treatment  of,  233 
Aerobic  bacteria.  23 
Agnew's  dressing  for  fracture  of  femur,  392 

operation  for  webbed  fingers,  521 

splint  for  patella.  396 
Air-passages,  foreign  bodies  in,  599 

883 


884 


INDEX. 


Albert's  disease,  2ig,  514 
Albuminuria  in  syphilis,  ig8 
Alcoholic  unconsciousness,  547 
Aleppo  boil,  740 

Alexander's  method  of  prostatectomy,  837 
method  of  treating  snake-bite,  178 
rules  fur  catheterization  in  hypertrophy  of 
prostate,  836 
Alexins,  32 
Alimentary  canal,  foreign  bodies  in,  633 

tuberculosis  of,  153 
Allingham"s  decalcified  bone  bobbin,  685 
method  of  excision  of  hemorrhoids,  716 
Allis  ether  inhaler,  729 

Aliis's   rule   for   reduction   of  dislocation   of 
femur,  465 
sign,  384,  463,  464 
Ailoxur  bodies  in  the  urine,  88 
Almen's  test  for  blood  in  urine,  764 
Alopecia  in  syphilis,  195 

treatment  of,  203 
Aluminum  probe,  Fluhrer's,  172 
Alveolar  sarcoma,  228 
Ambulatory  treatment  of  fractures,  336 
Amotile  bacteria,  17 
Amputation,  841 
a  la  manchette,  845 
at  ankle-joint,  853 

Pirogofif's  method,  853 
Syme's  method,  853 
at  elbow-joint,  849 
at  hip-joint,  857 

by  bloodless  method  of  Wyeth,  857 
Jordan's,  859 
Larrey's  method,  858 
Liston's,  854 
at  knee-joint,  855 
at  metacarpophalangeal  joint,  847 
at  middle  tarsal  joint,  852 
at  the  shoulder-joint,  849 

Dupuytren's  method,  859 
Larrey's  method,  849 
Lisfranc's  method,  850 
at  tarsometatarsal  articulation,  850 
Hey's  method,  852 
Lisfranc's  method,  850 
at  wrist-joint,  848 
by  transfixion,  846 
Chopart's,  852 
circular,  844 

modified,  845 
classification  of,  841 
during  shock,  164 
elliptical,  846 
flap  method,  846 
for  aneurysm,  254 
for  chondroma,  218 
for  compound  fracture,  339 
for  gangrene,  131 
for  gunshot-wounds,  174 
for  malignant  edema,  173 
for  osteoperiostitis,  311 
for  sarcoma  of  a  long  bone.  229 
for  snake-bite,  178 
in  diabetic  gangrene,  127,  128 
intermediate,  842 
methods  of,  844 
modified  circular,  845 
of  the  arm,  849 
of  fingers,  847 

distal  phalanx  of,  847 
middle  phalanx  of,  847 
proximal  phalanx  of,  847 
of  foot,  850 

Chopart's,  850 
Forbes's,  853 
Hey's,  852 
Lisfranc's,  850 


(  Amputation  of  forearm.       See    Amputation 
tliro7igh  /breariii. 
of  hand,  847 
of  leg,  854 

by  lateral  flaps,  855 

by  long  posterior  and  short  anterior  flap, 
855 

by  rectangular  flaps,  S54 

Garden's  method,  856 

Gritti's  method,  856 

just  below  knee,  855 

modified  circular,  854 

SabanejefTs  method,  856 

Sedillot's  method,  854 

Syme's  method,  855 

through  femoral  condyles,  855 

through  knee-joint,  855 
of  penis,  833 
of  thigh,  856 

Bell's  method,  857 
of  thumb,  848 
of  toes,  850 
oval,  846 

prevention  of  hemorrhage  in,  842 
primary,  a42 
racket,  846 
secondary,  842 
T-shaped,  858 
through  the  forearm,  848 
by  Teale's  method,  848 
Wyeth's  bloodless,  of  hip-joint,  857 
Amyloid  degeneration  due  to  syphilis,  198 
Anaerobic  bacteria,  23 
Anastomosis,  intestinal,  681 

rings,  681 
Anatomical  snuff-box,  282 

tubercle,  152 
Anderson's  method  of  tendon-lengthening,  519 
Anel's  operation  for  aneurysm,  252 
Anesthesia,  725 
by  freezing,  734 
general,  725 
local,  734 

preparation  for,  725 
primary,  732 

treatment  of  complications  of,  730 
Anesthetic  state  from  ether  or  chloroform,  729 
Anesthetics,  725 

Anesthetization  as  a  cause  of  shock,  162 
Aneurysm,  245 
acupressure  in,  255 
acute,  245 
amputation  for,  254 
arteriovenous.  245,  255 
by  anastomosis,  245,  256 
capillary,  246 
causes  of,  247 
circumscribed,  246 
cirsoid,  226,  246,  256 

symptoms  and  treatment  of,  257 
consecutive,  245 
cylindrical,  246 
diagnosis,  249 

from  cyst  or  abscess,  249 

from  growths  beneath  a  vessel,  249 
dissecting,  245 
electrolysis  in,  254 
embolic,  246 
false,  245 
forms  of,  245 
fusiform,  245 
miliary,  246 

-needle  of  Dupiiytren,  279 
of  bone,  245 
of  Saviard,  278 
operation  for,  Anel's,  252 

Antyllus's,  252 

Brasdor's,  254 


INDEX. 


885 


Aneurysm,  operation  for,  Hunter's,  252 
W'ardrop's,  254 
operative  treatment  of,  252 
Pott's,  255 
pulsation  of,  248 
sacculated,  245 
secondary, 246 
spontaneous,  246 
symptoms  of,  248 
traumatic,  245 
treatment  of,  250 

by  digital  pressure,  251 
by  direct  pressure,  251 
by  ligation,  252 
by  pressure,  251 
by  rapid  pressure,  251 
'Juffnell's  plan  of,  250 
traumatic,  255 
true,  245 
varicose,  255 

treatment  of,  256 
verminous,  246 
Aneurysmal  bruit,  248 
varix,  255 

symptoms  of,  256 
treatment  of,  250 
Angioma  of  mammary  gland,  864 
Angiomata,  225 
capillary,  225 
cavernous,  225 
plexiform,  226 
simple,  225 
treatment  of,  226 
Angular  curvature  of  spine,  583 
Ankle-joint  disease,  419 

dislocations  of,  471 
Ankylosis,  435 

extra-articular,  436 
false,  436 

treatment  of,  437 
fibrous,  435 
intra-articular,  435 
true,  435 

treatment  of,  435 
Anodynes  in  inflammation,  76 
Antagonistic  microbes,  36 
Antemortem  thrombus,  133 
Anterior  angular  splint,  Stromeyer's,  421 

triangle  of  the  neck,  201 
Anteroposterior  curvature  of  spine,  582 
Anthrax,  178 
benign,  740 
carbuncle,  179 

edema  of,  differentiation  from  cellulitis,  179 
external,  179 
forms  of,  179 
internal,  1  79 
intestinal,  180 
pulmonary,  180 
treatment  of,  179 
Antinosin,  28 

Antiphlogistic  regimen,  80 
Antipyretics  in  inflammation,  76 
Antisepsis,  42 
Antiseptic  poultice,  71 

as  a  wound  dressing,  166,  167,  175 
Antistreptococcic  serum,  36 
in  erysipelas,  142,  143 
in  septicemia,  138 
Antitoxin  of  tetanus,  148 
Antitoxins,  32 
Antivenene  serum,  178 

Antrum  of  Highmore,  diseases  and  injuries 
of,  596 
inflammation  and  abscess  of,  596 
Antyllus  operation  for  aneurysm,  252 
Anus,  diseases  and  injuries  of,  713 
fissure  of,  724 


Anus,  imperforate,  722 

prolapse  of,  717 

pruritus  (jf,  724 
Apathetic  shock,  162 
Aplastic  lymph,  92 
Appendicinal  abscess,  100 
Appendicitis,  647 

abdominal  section  in,  668 

catarrhal,  650 

etiology  of.  648 

foreign  bodies  as  a  cause  of,  649 

forms  of,  650 

gangrenous,  651 

obliterative,  650 

operation  for,  668 

pathology  of,  648 

simple  parietal,  650 

stercoral,  649 

suppurative,  651 

symptoms  of,  651 

terminations  of,  653 

traumatic,  649 

treatment  of,  653 
Appendicular  abscess,  100 
treatment  of,  103 

colic,  649,  650 

lilhiasis,  648 
Approximation   of   divided    intestines,    con- 
sideration of  methods  of,  693 
Arachnitis,  557 
Arcus  senilis,  121 

Ardor  urinae  in  gonorrhea,  treatment  of,  821 
Argonin,  29 

Aristol  as  a  drying-powder,  166 
Arm,  amputation  of,  849 
Arnot,  grafts  of  the  lining  membrane  of  hen's 

egg,  760 
Arterial  filter,  715 

pyemia,  139 

sclerosis  from  syphilis,  198 

sedatives  in  inflammation,  74 

transfusion,  278 
Arteries,  ligation  of,  in  continuity,  278 

wounds  of.  257 
Arteriovenous  aneurysm,  255 
Arteritis,  243 

acute,  243 

treatment  of,  244 

chronic,  243 

treatment  of,  244 

in  syphilis,  196 

obliterative,  244 

syphilitic,  244 
Arthrectomy,  485,  486 
Arthritis,  408 

acute  infantile,  318 
suppurative,  422 

deformans,  426 
symptoms  of,  427 
treatment  of.  428 

gonorrheal,  423 

gouty, 426 

in  hereditary  syphilis,  207 

infective,  422 

neuropathic,  429 

rheumatic,  425 

rheumatoid,  426,  'se.e.  Arthritis  deformans. 

tubercular,  408 

pathology  and  symptoms  of,  408 
treatment  of,  410 

typhoid,  422,  423 
Arthopathie  des  ataxiques,  439 
Arthropathy,  tabetic,  429 
Articular  neuralgia,  431 
Artificial  anus,  645 

leech,  Heurteloup's,  65 
Ascococci.  20 
Asepsis,  42 


886 


INDEX. 


Aseptic  fever,  87 

gauze,  46 

pus,  93 
Aseptic  wounds,  161 
Ashton's  aseptic  gauze  pads,  44 
Asphyxia,  local,  126 
Aspiration  of  joints,  488 
Aspirator,  pneumatic,  484 
Assaky  method  of  nerve-suturing,  531 
Astringents  in  inflammation,  68 
Ataxia  from  syphilis,  198 
Atheroma,  243,  244 
Atony  of  bladder,  790 
Atrophy  of  bone,  309 
concentric,  309 
eccentric,  309 

of  muscles,  505 

of  thyroid  gland,  743 
Autotransfusion  in  shock,  164 
Aveling  syringe  in  transfusion,  277 
Axillary  artery,  anatomy  of,  286 

ligation  of,  286-288 

Bacillus  anthracis,  41 

coli  communis,  41 

mallei,  41 

of  anthrax,  41 

of  glanders,  41 

of  gonorrhea,  39 

of  Koch,  149 

of  Loffler  a  cause  of  glanders,  182 

of  Lustgarten,  41 

of  malignant  edema,  41 

of  Neisser,  39 

of  Nicolaier,  144 

of  syphilis,  41 

of  tetanus,  144 

of  tuberculosis,  40,  149 

of  typhoid  fever,  41 

pyocyaneus,  39 

antagonistic  to  anthrax,  179 

pyogenes  foetidus,  39 

tetani,  40 

tuberculosis,  40,  149    ' 
Bacteria,  17 

aerobic  and  anaerobic,  23 

amotile,  17 

distribution  of,  30 

effect  of  motion,  heat,  and  cold  upon,  23 

life  conditions  of,  22 

motile,  17 

multiplication  of,  21 

parasitic, 19 

pathogenic,  19 

action  of,  31 

Bacterial  proteid,  31 

Bacteriology,  17-41 

Bacterium  coli  commune,  41 

termo,  41 
Balanitis,  816 

treatment  of,  821 
Balanoposthitis,  816,  821 
Bald  patch  in  syphilis,  194 
Baldness  from  syphilis,  195 
Bandage,  American,  of  the  foot,  751 

Barton's,  347,  752 

Borsch's,  for  eye,  753 

circular,  748 

cord,  758 

cravat,  758 

crossed,  of  angle  of  jaw,  753 
of  both  eyes,  752 

demi-gauntlet.  749 

Desault's,  756 

Esmarch's,  842 

figure-of-8,  of  both  eyes,  752 
of  jaw  and  occiput,  752 
of  thigh  and  pelvis,  754 


Bandage,  gauntlet,  749 
Gibson's,  347,  753 
Hamilton's,  347 
handkerchief,  758 
oblique,  of  jaw,  753 
oblong,  758 
of  elbow,  755 
of  foot  covering  the  heel,  751 

not  covering  the  heel,  751 

French,  751 
of  neck  and  axilla,  755 
plaster-of-Paris,  758 
recurrent,  of  head,  757 

of  stump,  758 
Ribbail's,  751 
Selva's  thumb,  750 
silicate-of-sodium,  759 
spica,  of  groin,  754 

of  instep,  751 

of  shoulder,  754 

of  thumb,  750 
spiral,  748 

of  all  the  fingers,  749 

of  foot  covering  the  heel,  751 

of  palm  or  dorsum  of  hand,  749 

of  upper  extremity,  748 

reversed,  of  lower  extremity,  750 
T-,  of  perineum,  758 
triangle,  75S 
Velpeau's,  755 
Bandages,  748 
Barker's  needle  for  wiring  fractured  patella, 

398 

operation  for  excision  of  vermiform  appen- 
dix, 669 

point,  539 
Barton's  bandage,  347,  752 

fracture,  377 
Basedow's  disease,  745 

Bassini,  method  of  operating  for  femoral  her- 
nia, 705 
Bassini's  operation  for  inguinal  hernia,  703 
Bayer,  treatment  of  spina  bifida,  578 
Beast-mimicry  in  hydrophobia,  181 
Bed-sore,  117,  130 
Bees,  stings  of,  176 

Belfield's'method  of  prostatectomy,  837 
Bellocq  cannula  in  packing  nares,  268 
Bell's  amputation  at  shoulder-joint,  850 

of  thigh,  857 
Benign  anthrax,  740.     See  Carhmcle. 

tumors,  214,  231 
Bent  tibia,  osteotomy  for,  477 
Bezold's  abscess,  563 
Bichat's  fissure,  location  of.  535 
Bier's  method  of  amputation  of  leg  by  lateral 
flaps,  855 

method  of  treating  tuberculosis,  56 
Bigelow's  evacuator,  803 

lithotrite,  804 

operation,  803 
Bigg's  apparatus  for  bunions,  515 
Bile-ducts,  rupture  of,  631 
Billroth's   method  of  lateral  intestinal  anas- 
tomosis, 682 
Bites  of  insects  and  reptiles,  176 

of  snakes,  177 
Black  sarcoma,  228 
Bladder,  aspiration  of,  787 

atony  of,  790 

chronic  catarrh  of,  796 

contusion  of,  787 

diseases  and  injuries  of,  784 

female,  growths  in,  809 

hemorrhage  from,  766 

inflammation  of,  794 

nervousness  of,  767 

operations  on,  799 


INDEX. 


%zr 


Bladder,  rupture  of,  788 

stone  in,  790.     See  Vesical  calculus. 

tumors  of,  798 

wounds  of,  788 
Blastomycetes,  18 
Bleeding  from  kidney,  764 

from  ureter,  764 

general,  in  inflammation,  73 

local,  in  inflammation,  63 
methods  of,  64 
Blind  boil,  740 
Blisters  in  inflammation,  72 
Bleeders,  263 

Bleeding.     See  Hemorrhage. 
Blood  in  urine,  tests  for,  763 

loss  of,  258 

-serum,  germicidal  power  of,  35.    See  Hem- 
orrhage. 

transfusion  of,  276 
Bloodletting  in  atheroma,  244 
Blue  ointment,  69 

pus,  95 
Bodine's  method  of  colostomy,  695 
Boil,  739.     See  Furuticle. 

Aleppo,  740 

blind,  740 
Bond's  splint,  379,  380 
Bone,  abscess  of,  312 
symptoms  of,  312 
treatment  of,  312 

actinomycosis  of,  309 

atrophy  of,  309 

as  a  predisposing  cause  of  fracture,  327 

caries  of,  313.     See  Caries. 

-chips  for  filling  bone  cavities,  317 
Seun's  decalcified,  48 

chronic  abscess  of,  108 

cyst  of,  309 

felon,  513 

ferrule,  Senn's,  481 

-grafting,  316 

gummata  of,  309 

healing  of,  86 

hypertrophy  of,  309 

inflammation  of,  309 

-marrow  in  treatment  of  osteomalacia,  321 

necrosis  of,  314 
from  osteitis,  310 

sclerosis  of,  from  osteitis,  310 

tubercular  diseases  of,  154 

tubercle  of,  309 

tumors  of,  309 
Bones,  affections  of,  in  syphilis,  195 

diseases  and  injuries  of,  309 

diseases  of,  309 

of   skull,   diseases   and    malformations   of, 
535 

operations  upon,  475 
Boric  acid,  29 

as  a  drying-powder,  166 
Borsch's  eye-bandage,  753 
Bose's  method,  603 

Bottini's  cauterization  of  prostate,  837 
Bougie,  esophageal,  621 

filiform,  786 
Bowel,  obstruction  of,  639 

ulcer  of,  646 
Bow-legs,  522 
Boyer's  cyst,  514 
Brachial  artery,  anatomy  of,  284 

ligation  of,  284-286 
Brain,  abscess  of,  100,  560 

compression  of,  545 

concussion  of,  543 

diseases  and  malformations  of,  541 

-disease  from  suppurative  ear  disease,  562 

hernia  of,  557 

inflammation  of,  557 


Brain,  laceration  of,  543 

malformations  of,  541 

-operations,  technique  of,  573 

syphilis,  190 

tumor  of,  562 

water  on,  559 

wounds  of,  554 
Brainard's  bone-drills,  482 
Brandt's  operation  of  stomach-reefing,  681 
Brasdor's  operation  for  aneurysm,  254 
Breast,  abscess  of,  loi,  860 

acute  abscess  of,  861 

chronic  abscess  of,  108 

diseases  of,  859 

inflammation  of,  860 
Bridge,  periosteal,  in  simple  fracture,  332 
Brodie's  abscess,  99,  106,  312 

joint,  430 
Bronchocele,  743 
Bronchus,  foreign  body  in,  600 
Brunonian  movements,  17 
Bruns's  upward  extension  method  of  leduc- 

ing  shoulder-joint  dislocations,  453 
Brush-burn,  167 

Bryant's   extension   for   fracture   of  thigh  ir» 
children,  394 

triangle,  384 
Bubo,  chancroidal,  831 

in  gonorrhea,  treatment  of,  821 

syphilitic,  190 
treatment  of,  199 
Buck's  extension-apparatus,  386 
Buffycoat,  62 
Bunion,  515 
Burns,  736 

symptoms  of,  736 

treatment  of,  736 

A'-ray,  874 
Bursitis,  514 

gluteal,  414 
Butcher's   method  of  excision  of  metatarsal 

bone  of  great  toe,  498 
Button,  Murphy's,  63i,  683 

Calculus,  renal,  772 

vesical,  790.     See  Vesical  calculus. 
Callous  ulcer,  117 
Callus,  333 

Calmette's  antivenene  serum,  178 
Calomel  as  a  drying-powder,  166 

fumigation  in  syphilis,  201 
Calyx-eyed  needle,  672 
Cancers,  233.     See  Carcinomata. 

adenoid,  236 

autotransference  of,  212 

causes  of,  210-212 

contagiousness  of,  211 

en  cuirasse,  867 

glandular,  236 

•houses,  211 

melanotic,  236 

of  lip,  operation  for,  618 

of  mammary  gland,  acinous,  866 
duct,  868 
treatment  of,  868 

of  penis,  833 

of  rectum,  720 
rest  in,  63 

of  stomach,  634 
symptoms  of,  634 
treatment  of,  635 

of  tongue,  differentiation  of,  from  chancer, 
189 
Cancerous  cachexia,  234 
Cancrum  oris,  129 
Cannon-balls,  wounds  by,  171 
Cannula  4  chemise,  270 
Capillary  angiomata,  225 


INDEX. 


Caput  medusae,  242 

succedaneum,  543 
Carbolic  acid,  25 

poisoning  by,  26 
Carbuncle,  740 

treatment  of,  741 
Carcinoma,  233.     See  also  Cancer. 

classification  of,  234 

colloid,  236 

cylindrical-celled,  236 

encephuloid,  236 

hematoid,  236 

of  mammary  gland,  866 

scirrhous,  235 

spheroidal-celled,  235 

telangiectactic,  236 

treatment  of,  236 
Carden's  amputation  of  leg,  856 
Cardia,  stenosis  of,  637 
Carditis,  240 
Caries,  313 

necrotica,  313 

of  spine,  583 

treatment  of,  586 

of  vertebrae,  Treves's  operation  for,  483 

sicca,  313 

symptoms  of,  313 

treatment  of,  314 

tubercular,  313 
Carotid  triangles,  inferior  and  superior,  292 
"  Carrying  function,"  loss  of,  as  a  symptom 
of   fracture  of   internal    condyle   of 
humerus,  369,  370 
Cartilage,  healing  of,  87 

inflammation  of,  54 
Cartilages,  floating,  437 
Caseation  of  tubercles,  149 
Caseous  abscess,  98 

pus,  95 
Castration,  839 

double,  for  myoma  of  prostate,  223 

for  sarcoma  of  testicle,  229 
Catarrh,  chronic  urethral,  817 
Catgut,  45 

chromicized,  45 

preparation  of,  45 
Catheter  coude,  787 

proper  curve  of,  786 
Catheterization  in  organic  stricture,  785 

in  spasmodic  stricture,  786 
Cauterization  of  snake-bites,  177,  278 
Cautery,  actual,  as  a  hemostatic,  262 
in  umbilical  hemorrhage,  269 

in  caries,  314 

in  treatment  of  anthrax  wound,  179 
Cavernous  angiomata,  225 

lipoma,  214 
Celiotomy,  666 
Cell-division,  85 

Cell-proliferation  in  inflammation,  53 
Cellulitis,  143 

diffused,  96 
Cellulocutaneous  erysipelas,  143 
Cementome,  219 
Centipedes,  sting  of,  176 
Cephalhematoma,  543 
Cephalic  tetanus,  145 
Cephalodynia,  504 
Cerebral  abscess  from  ear  disease,  563 

concussion,  162 

hemorrhage,  548,  549 

irritability,  544 
Cervical    lymphadenitis,    diagnosis    of,  from 

lymphadenoma,  155 
Chalk-stone,  426 
Chancer,  186 

and  chancroid,  mixed  infection,  188 
diagnosis  of,  188 


Chancer,  differentiation  of,  from  cancer  of  the 
tongue,  i8g 
from    chancroid,  188 
from  herpetic  ulceration,  189 
from  phagedenic  ulcer,  189 
hard,  187 
Hunterian,  187 
infecting,  187 
multiple,  187 

soft,  831.     See  Cha7zcroid. 
treatment  of,  199 
Chancroid,  1S8,  831 
mixed  infection,  188 
treatment  of,  832 
Chancroidal  bubo,  190 
Charbon,  178.     See  Anthrax. 
Charcot,  acute  bed-sore  of,  130 
Charcot's  disease,  429 
joint,  429 

spontaneous  dislocation  in,  439 
Cheese-cloth  dressings,  46 
Cheesy  abscess,  98 
Cheiloplasty,  618 
Chemical  germicides,  24 
Chemiotaxis,  17 
Chemotaxis,  17 
Chest,  contusions  and  wounds  of,  606 

diseases  and  injuries  of,  605 
Chiene's    method   of  locating  fissure  of  Ro- 
lando, 536 
Cheyne's  operation  for  femoral  hernia,  705 
Chilblain,  738 
Chionypha  Carteri,  19 
Chlorid  of  ethyl,  anesthesia  by,  734 
Chloroform,  administration  of,  728 
as  a  cause  of  shock,  163 
as  an  anesthetic,  726 
Cholecystenterostomy,  664,  697 
Cholecystostomy,  664,  697 
Choledochoduodenotomy,  664 
Choledochotomy,  664 
Cholelithiasis,  661 
Cholesteatoma,  217 
Chondromata,  217 
treatment  of,  218 
Chondrosarcoma,  229 
Chopart's  amputation,  852 
Chordee,  816 

Chromicized  catgut,  45  , 

Chronic  abscess,  98 
gangrene,  120 
tetanus,  145 
Choroiditis  in  syphilis,  196 
Cicatricial  stenosis  of  orifices  of  stomach,  637 
Cicatrization,  83 
Cinnamic  acid,  29 
Circumcision,  833 
Circumclusion,  262 
Circumscribed  abscess,  98 
Cirsoid  aneurysm,  226,  256.     See  Aneurysm. 
Clap,  815.     See  Gonorrhea. 
Clavicle,  dislocation  of,  445 
excision  of,  498 

fracture  of,  358,  362.     See  Fracture. 
Clavus,  741 
Cleft  palate,  612 

operation  for,  615 
Cloaca  of  bone,  315 
Closure  of  wounds,  166 
Clot,  "  active,"  247 
external,  257 
internal,  257 

removal  of,  from  wounds,  165 
Clove  hitch,  453 
Club-foot,  523.     See  Talipes. 
Club-hand,  523 

Cocain  hydrochlorate,  anesthesia  by,  734 
Cocain-poisoning,  73 


INDEX. 


889 


Coccidium  oviforme  as  a  cause  of  dilatation 

of  bile-ducts  in  rabbit,  212 
Coccus,  19 
Coccygodynia,  358 
Coccyx,  fracture  of,  357 
Cock's   operation    of    perineal    urethrotomy, 

830 
Cohnheim,  inclusion  theory  of,  210 
Coin-catcher,  626 
Cold  abscess,  98,  105,  106 
of  lymphatic  glands,  108 
effects  of.  738 
Coley's  method  of  treating  sarcoma,  230 
Colic,  appendicular,  651 
CoUes's  fracture,  277 

differentiation  of,  from  backward  disloca- 
tion of  the  wrist,  458 
immunity,  185 
law,  206 
Collin's  apparatus  for  transfusion,  277 
Colloid  carcinoma,  236 
Colopexy,  718 
Colostomy,  inguinal,  694 
Colpeurynter  in  rectal  hemorrhage,  269 
Coma,  varieties  of,  546 
Common  carotid  artery,  anatomy  of,  293 

ligation  of,  293-295 
Compression  of  brain,  545 
diagnosis  of,  546 

differentiation    of,  from  alcoholic   uncon- 
sciousness, 547 
from  apoplexy,  547 
from  diabetic  coma,  547 
from  hysterical  coma,  546 
from  opium-poisoning,  547 
from  post-epileptic  coma,  546 
from  uremic  coma,  547 
symptoms  of,  546 
treatment  of,  547 
of  spinal  cord,  592 
Concealed    hemorrhage,    diagnosis    of,   from 

shock, 163 
Concentric  atrophy  of  bone,  309 
Concrete  pus,  95 
Concussion,  cerebral,  162 
rest  in,  62 
of  brain,  543 

symptoms  of,  544 
treatment  of,  545 
of  spinal  cord,  591 
Condylomata,  flat,  193 

in  syphilis,  194 
Congenital  deformities  of  spine,  577 
hernia,  712 
hydrocele,  840 
phimosis,  833 
"  rickets,"  158 
wry-neck,  520 
Congestion  of  thyroid  gland,  743 
Congestive  abscess,  98 
Consecutive  abscess,  98 
Contagious  pus,  95 
Contraction,  Dupuytren's,  519 

of  muscles,  509 
Contused  wounds,  167 
Contusions,  160 

of  abdominal  wall,  626 
of  bladder,  787 
of  chest,  606 
of  head,  543 
of  muscles,  507 
of  nerves,  530 
of  spinal  cord,  591 
symptoms  of,  161 
treatment  of,  161 
with  gangrene,  161 
Cooper's   method   of   ligating   external    iliac 
artery,  408 


Cooper's   method  of  reducing   shoulder-joint 
dislocations,  453 
for  reduction  of  elbow-joint  dislocations, 

455 
Coraceous  abscess,  99 
Cord  bandage,  758 
Corn,  741 

treatment  of,  742 
Cornea,  inflammation  of,  54 
Corona  venerea,  193 
Corrosive  sublimate,  24 
Costal  cartilage,  fracture  of,  352 
Counterextension  in  fracture,  335 
Counlerirritants  in  inflammation,  72 
Counterirritation  in  ostitis,  311,  312 
Coxa  vara,  526 
Coxalgia,  pain  in,  57 

Coxitis,     411.       See     Tu/ierculosis    of    hip- 
joint. 
Craniocerebral  topography,  535-539 
Craniometrical  points,  536 
Craniotomy,  linear,  577 
Cravat,  758 

Crawling  paralysis,  592 
Crepitation  in  fracture,  329 
Crepitus  in  fracture,  329 
Crequy's  method  of  removing  foreign  bodies 

from  esophagus,  626 
Cretinism,  743 
Cripp's  operation,  720 
Critical  abscess,  98 
Croupous  lymph,  92 
Cuneiform  osteotomy,  475,  477 
Cupping,  65 

of  blood-clot,  62 
Curdy  pus,  95 
Curling's  ulcer,  646 
Curvature  of  spine,  580 
angular,  583 
anteroposterior,  582 
lateral,  580 
Cushuig's  right-angled  suture,  673 
Cut  throat,  598 
Cutaneous  erysipelas,  141 
Cuticular   membrane   of    echinococcus   cyst, 

239 
Cyanosis  from  use  of  acetanilid,  28 
Cylindroma,  229 
Cyrtometer,  537,  539 

Horsley's,  536 
Cyst,  lacteal,  865 

of  mammary  gland,  864 
Cystic  goiter,  743 
Cystitis,  794 

acute,  symptoms  of,  795 
treatment  of,  795 

chronic,  symptoms  of,  796 
treatment  of,  796 

from  gonorrhea,  treatment  of,  821 

rest  in,  63 

tubercular,  798 
Cystocele,  699 
Cystotomy,  808 

in  cystitis,  63 

median,  809 

suprapubic,  808 

for  hemorrhage  from  prostate,  270 
for  myoma  of  the  prostate,  223 
Cysts,  237 

dentigerous,  219 

dermoid,  238 

treatment  of,  238 

hydatid,  238 

treatment  of,  239 

of  pancreas,  665 

sebaceous,  237 
treatment  of,  238 

varieties  of,  237 


890 


INDEX. 


Czerny-Lembert  suture,  673 

Czerny's  method  of  tendon-lengthening,  519 

Dactylitis  in  syphilis,  207 
Dalton,  suture  of  the  pericardium,  240 
"  Dangerous  area,"  540 
Darier,  psorosperm,  212 
D'Arsonval's  case  of  electric  stroke,  880 
Davaine,  method  of  treating  malignant  pus- 
tule, 180 
Davy's  director,  479 
DecoUement  of  parietal  pleura,  612 
Decubital  gangrene,  130 

ulcer,  117 
Decubitus,  117,  130 
Deep  abscess,  09 
Degeneration,  gelatiniform,  409 

of  muscles,  505 

pulp}-,  408 

reactions  of,  527 
Delayed  union,  treatment  of,  341 
Delirious  shock,  163 
Delirium  in  shock,  163 
Delitescence  of  inflammation,  55 
Demarcation,  line  of,  121 
Demigauntlet  bandage,  749 
Demosthen's  studies  of  action  of  Mannlicher 

rifle,  160 
Dentigerous  cysts,  219 
Depletion  in  inflammation,  63 
Depression-fracture,  522 
Dermatitis  venenata,  739 
Dermoid  cysts,  238 
Desault's  apparatus,  756 

bandage  in  fracture  of  clavicle,  360,  361,  446, 
447 
in  fracture  of  humerus,  364 
in  fracture  of  scapula,  362,  363 

sign,  384 
Descendens  noni  nerve  as  a  guide  to  sheath 

of  common  carotid  in  ligation,  293 
Diabetic  gangrene,  127 
Diapedesis  in  inflammation,  52 
Diaphoretics  in  inflammation,  75 
Diaphragmatic  hernia,  713 
Diarrhea  of  constipation,  642 
Diastasis,  324 
Diathetic  abscess.  98 

Dickinson's  theory,  amyloid  degeneration,  415 
Diday's  operation  for  webbed  fingers,  521 
Diefienbach   plan  of    treating  old  traumatic 

dislocations,  444 
Diffuse  lipoma,  214 
Diffused  abscess,  98 

Digestive  tract,  diseases  and  injuries  of,  612 
Digital  dilatation  of  pylorus,  674 
Digits,  supemumeraiy,  521 
Diphtheria,  tracheotomy  in,  603 
Diplococci,  20 

Diplococcus  of  gonorrhea,  39 
Direct  cell-division,  85 
Disarticulation  at  ankle-joint,  853 

at  elbow-joint,  849 

at  hip-joint,  857 

at  knee,  855 

at  metacarpophalangeal  joint  of  hand,  847 

at  shoulder-joint,  849 

at  tarsometatarsal  articulation,  850 
Disease  production,  31 

of  esophagus,  612 

of  genito-urinary  organs,  763 

of  the  head,  535 

of  the  joints,  406 

of  kidney,  768 

of  lymphatics,  746 

of  mouth,  612 

of  rectum  and  anus,  713 

of  scalp,  539 


Disease  of  skin  and  nails,  739 
of  thyroid  gland,  743 
of  tongue,  612 
Disinfection  of  hands,  43 
of  instruments,  44 
of  patient,  44 
Dislocated  kidney,  769 

Dislocations  at  metacarpophalangeal  articula- 
tions, 459 
axillary,  449 
bilateral,  439 
complete,  438 
complicated,  438 
compound,  438 

traumatic,  443 
congenital,  439 
consecutive,  439 
double,  438 
habitual,  439 
incomplete,  438 
Monteggia's,  467 
Nelaton's,  472 
of  ankle-joint,  471 

anteroposterior,  472 

lateral,  471 

upward,  472 
of  astragalus,  473 
of  carpal  bones,  459 
of  clavicle,  445 

acromial  end,  447 

backward,  of  sternal  end,  446 

sternal  end,  forward,  445 

upward,  446 
of  costal  cartilages,  461 
of  elbow-joint,  454 

backward,  455 

forward,  455 

inward,  456 

outward,  456 
of  femur,  461 

downward  into  obturator  foramen,  465 

ischial,  467 

on  to  dorsum  of  ilium,  462 

on  to  the  pubes,  466 

into  sciatic  notch,  464 

Monteggia's,  467 

perineal,  4O7 

subspinous,  467 

suprapubic,  467 

supraspinous,  466 

with  catching  up  of  sciatic  nerve  upon 
reduction,  467 
of  fibula,  471 
of  forearm,  lateral,  456 
of  head   of   femur  with  fracture  of  shaft, 

467 
of  hip,  anomalous,  466 

congenital,  operation  for,  503 
of  hip-joint,  461.  See  Dislocations  of fe^nur . 
of  humerus,  448 

of  inferior  radio-ulnar  articulation,  459 
of  knee,  468 

backward,  468 

forward,  468 

inward,  469 

outward,  469 
of  lower  jaw,  444 
of  metacarpal  bones,  459 
of  metacarpophalangeal  joint,  459 
of  metatarsal  bones,  474 
of  muscles,  509 
of  patella,  469 

edgewise,  470 
of  pelvis,  461 
of  phalanges,  460,  474 
of  radius  backward,  457 

forward,  456 

outward,  457 


INDEX. 


891 


Dislocations  of  ribs,  461 
of  scapula,  lower  angle,  448 
of  semilunar  cartilages  of  knee,  470 
of  shoulder-joint,  448 
diagnosis  of,  451 
reduction  by  extension,  452 
symptoms  of,  449 
treatment  of,  451 
of  spine,  592 
of  sternum,  461 
of  tarsal  bones,  474 
of  tendons,  cog 
of  ulna  at  elbow-joint,  456 
of  ulnar  nerve  at  elbow,  529 
of  the  wrist,  458 
backward,  458 
forward,  458 
old,  438 
partial,  448 
pathological,  449 
primitive,  438 
recent,  43S 
relapsing,  439 
sacro-iliac,  461 
secondary,  438 
simple,  438 
single,  438 
spontaneous,  439 
subastragaloid,  473 
subclavicular,  449 
subcoracoid,  448 
subglenoid,  449 
subspinous,  449 
traumatic,  438 
causes  of,  440 
compound,  443 
diagnosis  of,  441 
old,  443 

pathological  conditions  of,  440 
recent  simple,  442 
special,  444 
symptoms  of,  441 
treatment  of,  442 
unilateral,  438 

with  fracture,  treatment  of,  338 
Dislocations,  438 
Displaced  liver,  661 
Displacement  in  fracture,  327 

in  plastic  surgery,  760 
Dissection-wounds,  175 
Diuretics  in  inflammation,  76 
Diverticula  of  esophagus,  623 
Division  of  sternocleidomastoid  for  wry-neck, 

316 
Donnellan'b  case  of  electric  stroke,  880 
Dorsal  abscess,  107 

Dorsalis  pedis  artery,  ligation  of,  298,  299 
Douche  in  inflammation,  69 
Doyen,  exploratory  operation  of,  573 
Drainage,  47 

of  wounds,  166 
Dressings,  gauze,  46 

of  wounds,  166 
Dropsy,  407 

of  joint  in  gonorrheal  arthritis,  424 
Dry  aseptic  method,  42 
cold  in  inflammation,  66 
gangrene,  119,  120 
treatment  of,  122 
heat  in  inflammation,  71 
Drying-powder  in  wound  dressings,  i66 
Duality  theory  of  syphilitic  infection,  187 
Dugas's  sign,  449 

Dupuytren's  aneurysm-needle,  279 
classification  of  burns,  736 
contraction,  520 

symptoms  of,  521 
fracture,  472 


Dupuytren's    operation    for    amputation     at 
shoulder-joint,  850 
splint,  403 
suture,  673 

Ear.  affections  of,  in  syphilis,  195 

disease,  cerebral  abscess  from,  563 
brain-disease  from,  562 
Eberth's  bacillus,  41 
Eccentric  atrophy  of  bone,  309 
Ecchondroses,  218 
Ecchymosis,  160 
Echinococcus   as   a   cause   of  hydatid   cysts, 

238 
Eczematous  urethritis,  815 
Edebohls's  method  of  treating  mobile  kidney, 
770 
of  nephrotomy,  780 
Edema,  91 

from  fracture,  treatment  of,  338 

in  anthrax,  179 

malignant,  from  wounds,  175 

of  glottis,  598 

of  larynx,  598 

periarticular,  407 

treatment  of,  gi 
"  Educated  corpuscle,"  34 
Elbow,  miners',  515 

-joint  disease,  420 
dislocations  of,  454 
excision  of,  490 
Election,  triangle  of,  292 
Electric  stroke,  effects  of,  880 

treatment  of,  S80 
Electricity,  injuries  by,  878 
Electrolysis  in  aneurj'sm,  250,  254 

in  angiomata,  226 
Electropuncture  for  cirsoid  aneurysm,  257 

for  delayed  union  of  fractures,  341 
Elephantiasis,  747 

arabum,  747 
Elevation  in  treating  contusions,  161 

in  treating  inflammation,  63 

in  treatment  of  hemorrhage,  262 
Embolic  abscess,  98 
Embolism,  134 

fat,  135 

symptoms  of,  134 

treatment  of,  135 
Embryonic  tissue,  53 

formation  of,  in  healing,  83 
formation  of,  in  inflammation,  91 
Emphysema,  gangrenous,  125 

from  wounds,  175 
Emphysematous  abscess,  98 
Emprosthotonos  in  tetanus,  145 
Empyema,  102,  605 
En  bissac,  reduction  of  hernia,  710 
Encephalitis,  559 
Encephalocele,  541 
Encephaloid  carcinoma,  236 
Enchondromata,  217.     See  Chondromata. 
Encysted  abscess,  99 
Endarteritis  in  syphilis,  196 
Endo-appendicitis,  651 
Endocyst,  239 
Endospore,  22 
Enterectomy,  681 
Enteritis,  rest  in,  63 
Enterocele,  699 
Enteroclysis  in  shock,  163 
Entero-epiplocele,  699 
Enteroliths  in  obstructed  bowel,  640 
Enterorrhaphy,  671 
Enterostenosis,  639 
Enterostomy,  694 
Epididymitis,  839 

in  gonorrhea,  816 


892 


INDEX. 


Epididymitis  in  gonorrhea,  treatment  of,  822 

in  syphilis,  196 
Epigastric  hernia,  713 
Epilepsy,  operative  treatment  of,  569 
Epiphyseal  separation,  324 
Epiphysitis,  acute,  318 
symptoms  of,  319 
treatment  of,  319 

in  hereditary  syphilis,  207 
Epiplocele,  690 
Epispadias,  S30 
Epistaxis,  treatment  of,  268 
Epithelioid  cells,  83 
of  tubercle,  148 
Epitheliomata,  234 
Epulis,  treatment  of,  217 
Equinia,  182 
Equinovariis,  524 
Erasion  of  a  joint,  485,  486 
Erethistic  shock,  163 

ulcer,  116 
Erichsen  suture   in  treatment  of  angiomata, 

227 
Erichsen's  signs  of  dislocation   of  shoulder- 
joint,  450 
Erysipelas,  140 

antistreptococcic  serum  in,  142 

cellulocutaneous,  142 

clinical  forms  of,  141 

cutaneous,  141 

discoloration  in,  59 

forms  of,  141 

phlegmonous,  142 

streptococcus  of,  38,  39 

varieties  of,  140 
Erysipele  salutaire,  142 
Erythema  of  syphilis,  192 
Escherich,  bacillus  of,  41 
Esmarch  bandage  in  aneurysm,  251 

use  of,  in  shock,  164 
Esmarch's  cooling  coil,  67 

elastic  bandage,  842 

operation  for  ankylosis,  436 

package  of  dressing  for  soldiers.  174 

splint  for  excision  of  elbow-joint,  491 
Esophagus,  diverticula  of,  623 

foreign  bodies  in,  624 

injuries  of,  624 

stricture  of,  620 
Estlander's  operation,  6io 
Ether,  administration  of,  729 

as  an  anesthetic,  726 

spray,  anesthesia  by,  734 
Ethereal  soap  of  Johnston,  43 
Ethyl  bromid  as  an  anesthetic,  733 
Eucain  hydrochlorate  as  an  anesthetic,  735 
Eucalyptol,  29 
Europhen,  28 

Evacuation,  spontaneous,  98 
Eversion  of  leg  in  intracapsular  fracture  of 

femur,  383 
Ev/ald's  test-breakfast  in  cancer  of  stomach, 

634 
Excision  of  ankle-joint,  496 

of  astragalus,  498 

of  bones  and  joints,  485 

of  clavicle,  498 

of  elbow-joint,  490 

of  hemorrhoids,  716 

of  hip-joint,  493 

by  anterior  incision,  494 
by  lateral  incision,  494 

of  knee-joint,  486,  495 

of  lower  jaw,  502 

of  metacarpal  bones,  493 

of  metatarsal  bone  of  great  toe,  498 

of  metatarsophalangeal  articulation  of  great 
toe,  498 


Excision  of  os  calcis,  497 

of  phalanges,  493 

of  pylorus,  675 

of  rectum,  720 

of  rib,  499 

of  scapula,  499 

of  shoulder-joint,  487 
by  anterior  incision,  489 
by  deltoid  flap,  489 
Senn's  method,  490 

of  upper  jaw,  complete,  500 

of  wrist-joint,  491 
Exfoliation,  315 
Exophthalmic  goiter,  745 
Exostosis,  218 

Exploratory  laparotomy,  644 
Explosive  effects  of  projectiles,  169 
Extension  for  reduction  of  shoulder-joint  dis- 
locations, 452 
External  anthrax,  179 

clot,  257 
Extracapsular  fracture  of  femur,  389 
Extradural  abscess,  560,  564 

hemorrhage,  547,  548 
ExtrameduUary  hemorrhage,  266 
Exuberant  ulcer,  116 
Eye,  syphilitic  affections  of,  196 

Fabricius'  operation  for  femoral  hernia,  706 
Facial  artery,  ligation  of,  297 
Facultative-aerobic  bacterium,  23 
Farcy, 182 

-buds,  182 
Fasciotomy  of  plantar  fascia,  517 
Fat-embolism,  135 

diagnosis  of,  from  shock,  163 

-hernia,  215 
Fecal  abscess,  99 

fistula,  645 
Senn's  operation  for,  694 
Fehleisen's  coccus,  39 

streptococcus,  140 
Fell's  method  of  artificial  respiration,  732 
Felon,  loi,  512 

bone,  513 

deep,  513 

superficial,  513 

treatment  of,  513 
Femoral  artery,  ligation  of,  303-305 

hernia,  712 
Femur,  dislocations  of,  461 

fracture  of,  382 
Fenestrated  p!aster-of-Paris  dressing  for  com- 
pound fracture,  340 
Fenger's  incision,  679 

Fergusson's  method  of  treating  varix  of  leg, 
274 

operation  for  clefts  of  hard  palate,  616 
Ferment,  17 
Fermentation,  17 
Fever,  aseptic,  87 

essential  phenomena  of,  87 

hectic,  89,  100 

hemorrhagic,  259 

in  acute  inflammation,  61 

inflammatory,  61 

of  iodoform  absorption,  27 

of  tension,  89 

suppurative,  89 

surgical,  87,  88 
scarlet,  90 

symptomatic,  61 

syphilitic,  191 

urethral,  829 

traumatic,  87 
Fibrinous  pus,  95 
Fibro-adenoma,  232 

of  mammary  gland,  863 


INDEX. 


893 


Fibromata,  215 

treatment  of,  217 
Fibrosarcoma,  229 
Fibrous  epulis,  216 

union,  333 
Fibula,  fracture  of,  401 
Filaria  sanguinis  hominis  as  a  cause  of  lym- 

phangiectasis,  226 
Filiform  bougie,  786 
Fingers,  amputation  of,  847 
First  intention,  healing  by,  82 
Fish-mouth  meatus,  816 

Fiske's  plan  for  detecting  joint-effusions,  407 
Fission  of  bacteria,  21 
Fissure,  322 

intraparietal,  538 

of  anus,  724 

of  Bichat,  location  of,  535 

of  nipple,  859 

prevention  of,  859 

of  Rolando,  location  of,  535 

of  Sylvius,  location  of,  537 
Fistula,  118 

fecal,  645 

in  ano,  722 

treatment  of,  723 
Fixed  dressings,  758 
Flail-joints,  527 
Flat  condylomata,  193 

foot,  525 
Flexion,  forced,  as  a  hemostatic,  263 
Floating  cartilages,  437 

kidney,  768 
Fluhrers  aluminum  probe,  172 
Fluorid  of  sodium,  29 
Fluoroscope,  872,  873 

for  locating  bullets,  173 

in  detecting  fractures,  331 
Fluoroscopy,  value  of,  S73 
Follicular  abscess,  99 
Forbes's  lithotrite,  804 

method  of  amputation  through  tarsus,  853 
Forcible  correction  in  Pott's  disease,  587 
Foreign  bodies  in  air-passages,  599 
in  alimentary  canal,  633 
in  bronchi,  600 
in  esophagus,  624 
in  larynx,  599 
in  rectum,  721 
in  trachea,  600 
in  urethra,  813 

removal  of,  from  wounds,  165 
Formaldehyd,  29 
Formalin,  29 

-gelatin,  29 

gut,  45 
Formative  lymph,  92 
Formic  aldehyd,  29 

Fort's  electrolysis  of  urethral  stricture,  828 
Fowler's  catgut,  45 

classification  of  appendicitis,  651 

operation  for  inguinal  hernia,  705 

probe  for  gunshot-wounds  of  head,  556 
Fox's  clavicle-splint,  360 
Fractures,  321-406 

ambulatory,  treatment  of,  336 

Barton's  377 

bent,  322 

by  contre-coup,  324 

by  indirect  force,  325 

capillary,  322 

causes  of,  324 

comminuted,  323 

complete,  322 

complicated,  321 

complications  of.  322 

prevention  and  treatment  of,  337 

composite,  •523  . 


Fractures,  compound,  321 

amputation  for,  339 

primary,  321 

repair  of,  334 

secondary,  321 

treatment  of,  339 
consequences  ot,  332 
counterextension  in,  335 
crepitus  or  crepitation  in,  329 
cuneated  or  cuneiform,  323 
deformity  of  part  in,  327 
delayed  union  of,  334 
dentate,  323 
depression-,  322 
diagnosis  of,  330 

by  A'-ray,  330,  331 
direct,  323 

-dislocation  of  spmal  cord,  593 
symptoms  of,  593 
treatment  of,  c.93 
displacement  in,  v>irieties  of,  327 
distinguishing  of,  from  dislocation,  330 
Dupuytren's,  472 
ecchymosis  in,  328 
en  coin,  323 
en  rare,  323 
en  V,  323 

exciting  causes  of,  324 
extracapsular,  324 
extrav^-sation  of  blood  in,  328 
fissured,  322 

from  direct  violence,  324 
from  external  violence,  324 
from  muscular  action,  325 
green-stick,  322 
hair,  322 
helicoidal,  324 
hickory-stick,  322 
-hook  of  McBurney  and  Dowd,  338 
immovable  dressing  in,  336 
impacted,  323 
in  elbow-joint,  371 
incomplete,  322 
indirect,  324 
intra-articular,  324 
intracapsular,  324 
intrauterine,  324 
linear,  322 
longitudinal,  322 
loss  of  function  in,  328 
massage  in,  336 
multiple,  323 
near  elbow-joint,  371 

nervous  disease  as  predisposing  cause  of,  326 
non-union  of,  334 
oblique.  322 

spiroide,  323 
of  acetabulum,  356,  386 
of  bones  of  foot,  404 
of  both  bones  of  leg.  403 
of  brim  of  acetabulum,  386 
of  carpus,  381 
of  clavicle,  358-362 

acromial  end  of,  j6i 

in  the  shaft.  358 

complications  of.  359 
symptoms  of,  358 
treatment  of,  359 

sternal  end  of,  362 
of  coccyx,  357 
of  costal  cartilage,  352 
of  false  pelvis,  344 
of  femur,  382 

at  the  base  of  the  neck,  389 

extracapsular.  389 
impacted  form,  390 

great  trochanter  of,  390 

intracapsular,  382-388 


894 


INDEX. 


Fractures  of  femur,  intracapsular,  differentia- 
tion of,  from  extracapsular,  385 

just  above  condyles,  394 

longitudinal,  395 

separating  either  condyle,  395 

separation  of  the  epiphysis  of  the  great 
trochanter,  391 

separation  of  lower  epiphysis,  395 

shaft  of,  391 

upper  epiphysis  of  head  of,  390 

upper  extremity  of,  382 
of  fibula,  401 

lower  third  of,  402 

upper  two-thirds  of,  402 
of  forearm,  both  bones  of,  377 
of  humerus,  363 

anatomical  neck  of,  363 

at  lower  epiphysis,  373 

at  upper  epiphysis,  367 

base  of,  condyles  of,  370 

external  condyle  of,  369 

head  of,  366 

inner  epicondyle  of,  369 

internal  condyle  of,  369 

lower  extremity  of,  369 

shaft  of,  367 

surgical  neck  of,  364 

T-fracture,  371 

upper  extremity  of,  363 
of  hyoid  bone,  348 
of  inferior  maxillary,  346 
complications  of,  347 
symptoms  of,  347 
treatment  of,  347 
of  ischium,  357 
of  lachrymal  bone,  343 
of  laryngeal  cartilages,  349 
of  leg,  400 
of  malar  bone,  345 
of  metacarpal  bones,  381 
of  metatarsal  bones,  405 
of  nasal  bones,  342 

treatment  of,  342 
of  patella,  395 

by  direct  force,  398 

by  muscular  action,  395 

transverse,  396 
of  pelvis,  354 
of  penis,  833 
of  phalanges,  381 
of  toes,  408 
of  radius,  375 

above   insertion  of  pronator  radii   teres 
muscle,  376 

i\nd  ulna  near  wrist,  381 

below  insertion   of  pronator  radii   teres 
muscle,  376 

head  of,  375 

lower  extremity  of,  377 

neck  of,  376 

shaft  of,  376 
of  ribs,  349 

causes  of,  350 

complications  of,  351 

symptoms  of,  350 

treatment  of,  351 
of  sacrum,  357 
of  scapula,  362 

acromion  of,  362 

coracoid  process  of,  363 

glenoid  cavity  of,  362 

neck  of,  362 
of  skull,  549 

base  of,  551 

vault  of,  550 
of  spine,  592 
of  sternum,  353 

causes  of,  353 


Fractures  of  sternum,  complications  of,  353 

symptoms  of,  353 

treatment  of,  353 
of  superior  maxillary,  344 
of  tibia,  by  separation  of  lower  epiphysis, 
401 

by  separation  of  upper  epiphysis,  400 

inner  malleolus,  401 

lower  end  of,  401 

shaft  of,  400 

upper  end  of,  400 
of  true  pelvis,  355 
of  ulna,  373 

coronoid  process  of,  373 

olecranon  process  of,  373 

styloid  process  of,  375 
of  zygomatic  arch,  346 
overlapping  of  fragments  in,  328 
overriding  of  fragments  in,  328 
pain  in,  327 
pathological,  323 
penetration  of  fragments  in,  328 
Pott's,  402 

predisposing  causes  of,  325 
preternatural  mobility  in,  329 
radish,  323 

recent,  operative  treatment  of,  480 
reduction  of,  335 
repair  of,  333 
rest  in,  62 
secondary, 323 

separation  of  fragments  m,  328 
simple,  321 

repair  of,  332 
sound  of  cracking  in,  327 
spiral,  324 
splinter-,  322 
spontaneous,  323 
starred,  324 
stellate,  324 
strain,  322 
swelling  in,  327 
symptoms  of,  327 

circumstantial,  340 

direct,  330 
transverse,  322 
treatment  of,  334 

of  edema  from,  338 

of  gangrene  from,  338 

of  inflammation  m,  339 

of  phlebitis  from,  338 
^of  sloughing  in,  337,  338 
T-shaped,  323 
toothed,  323 
torsion,  324 
imion  ol,  fibrous,  333,  334 

ligamentous,  334 

membranous,  334 

vicious,  334 
ummited,  323,  334 

operative  treatment  of,  482 

treatment  of,  341 
varieties  of,  321 
V-shaped,  323 
vicious  union  of,  334 
wedge-shaped,  323 
willow,  322 
wiring  of,  336 
with  crushing,  323 
with  dislocation,  treatment  of,  338 
with  penetration,  323 
Freezing,  anesthesia  by,  734 
Frontal  sinus,  distention  and  abscess  of,  597 

trephining  of,  573 
Frost-bite,  gangrene  from,  128 

treatment  of,  738 
Fuller's  method  of  "  milking  "    the   seminal 
ducts,  834 


INDEX. 


895 


Fuller's  method  of  prostatectomy,  837 
Fulminating  gangrene,  125 
Fungi,  18 
Fungous  ulcer,  116 
Fungus  cerebri,  557 

haematodes,  227 
Funicular  hernia,  712 
Furuncle,  739 

symptoms  of,  740 
Furunculosis,  740 

Galactocele,  865 
Gall-bladder,  rupture  of,  631 
Gall-stones,  661 

causes  of,  661 

symptoms  of,  662 

treatment  of,  663 
Ganglia,  512 

treatment  of,  512 
Gangrene,  119 

acute,  124 

amputation  for,  131 

classification  of,  119 

chronic,  120 

decubital,  130 

diabetic,  127 

discoloration  in,  59 

dry,  119,  120 

foudroyante,  125 

from  contusion,  treatment  of,  161 

from  ergotism,  12S 

from  fracture,  treatment  of,  338 

from  frost-bite,  128 

from  infective  organisms,  125 

fulminating,  125 

hospital,  125 

moist,  119,  124 

of  lung,  607 

of  penis,  833 

postfebrile,  131 

Pott'b,  120 

Raynaud's,  126 

senile,  121 

septic,  119 

symmetrical,  126 

traumatic  spreading,  125 
Gangrenous  emphysema,  125 

from  wounds,  175 
Garel's  sign,  loi 

Gasserian  ganglion,  removal  of,  533 
Gastro-enterostomy,  180 

for  cancer  of  pylorus,  237 

for  pyloric  obstruction,  639 
Gastrogastrostomy,  681 
Gastroplication,  681 
Gastrostomy,  678 

for  cancer  of  esophagus,  237 
Gastrotomy,  676 

in  cardiac  stenosis,  639 
Gauntlet,  749 
Gauze,  iodoform,  preparation  of,  46 

Lister's  cyanid,  47 

pads,  Ashton's,  44 

sterilized,  preparation  of,  46 
Gelatiniform  degeneration,  409 
Genito-urinary  diseases,  pain  in,  766 

organs,  diseases  and  injuries  of,  763 
Genu  valgum,  522 

osteotomy  for,  475 

varum,  522 
Germicides,  chemical,  24 
Giant-cell  sarcoma,  228 
Gibney,  method  of  treating  sprains,  434 
Gibson's  bandage,  347,  753 
Gila  monster,  bite  of,  178 
Girdle-pain  in  tetanus,  145 
Girdner's  telephonic  probe,  173 
Glanders,  182 


Glanders,  diagnosis  of,  182 

treatment  of,  182 
Glandula:  Pleiades  of  Ricord,  190 
Glandular  cancer,  236 
Gleet,  817 

Glenard's  disease,  661 
Gliosarcoma,  229 
Globus,  621 
Glottis,  edema  of,  59S 
Glovers'  stitch,  46 
Gliick  and  Bartholow,  anesthetic  mixture  of, 

735 
Gluteal  artery,  ligation  of,  308 

bursitis,  414 
Glutol,  29 

in  dressing  wounds,  166 
Goiter,  743 

cystic,  743 

exophthalmic,  745 

fibrous,  744 

pulsating,  745 

symptoms  of,  744 

treatment  of,  744 
Gonococci,  determination  of,  817 
Gonococcus,  39 
Gonorrhea,  S15 

abortive,  817 

acute  inflammatory,  816 
treatment  of,  S18 

black,  816 

catarrhal,  817 

in  the  female,  823 

irritative,  817 

of  rectum,  823 

subacute,  817 
Gonorrheal  arthritis,  423 

changes  in  ihe  joints  in,  424 

ophthalmia,  822 

rheumatism,  423 
Gordon's  pistol-shaped  splint,  379 
Gouley's  divulsor,  826 

tunnelled  catheter,  785 
Gout,  rheumatic,  427.     See  Arthritis  de/or- 

fnatzs. 
Gouty  arthritis,  426 
Graft,  omental,  674 
Grant's  clamp,  697 

operation,  478 
Granulation,  healing  by,  84 

-tissue,  53 
in  repair  of  fractures,  3j2 
Graves's  disease,  745 
Gravitative  abscess,  98 
Green-stick  fracture,  322 
Gntti's  amputation  of  leg,  856 
Gross,  antimonial  and  saline  mixture,  74 

incision  of,  495 
Gross's  divulsor,  826,  828 

method  of  amputation  at  elbow-joint,  849 

rule   for  continuous   treatment  of  syphilis, 
200 

urethrotome,  826,  828 
Guerin's  method  of  amputating  fool,  852 
Guiteras's  (Ramon)  method  of  examining  for 

urethral  stricture,  825 
Gumma  in  tertiary  syphilis,  197 
Gummy  pus,  95 
Gunshot-wounds,  168 

amputation  for,  174 

dressing  of,  173 

hemorrhage  in,  171,  268 

of  arteries,  258 

of  head, 555 

treatment  of,  556 

pain  from,  172 

shock  from,  172 

symptoms  of,  171 

treatment  of,  172 


896 


INDEX. 


Gussenbauer's    clamp    in   delayed   union   of 
fractures,  341 
suture,  673 
Guthrie's  rule  for  treatment  of  hemorrhage, 

263 
Guyon's  method  of  sterilizing  catheters,  836 

Hagedorn  needle,  >ise  of,  in  ligation,  260 
Hair,  affections  of,  in  syphilis,  195 
Hahn,  method  of  gastrostomy,  679 
Hallux  valgus,  525 

varus,  525 
Halsted's  inflatable   rubber   cylinder  for  cir- 
cular enterorrhaphy,  687 

mattress-suture,  673 

method   of   lateral  intestinal    anastomosis, 
691 

operation  for  cancer  of  breast,  868 
for  inguinal  hernia,  704 

subcuticular  stitch,  42,  704 
Hamilton's  bandage   for   fracture  of  inferior 
maxillary,  347 

bone-drills,  482 
Hammer-toe,  526 

Hancock's  method  of  excising  ankle-joint,  497 
Handkerchief  bandages,  758 
Hands  of  operator,  disinfection  of,  43 
Hard  chancer,  187 
Harelip,  612 

operation  for,  613 
Harris's    method  of  circular  enterorrhaphy, 

687 
Hayden's  treatment  of  chancroidal  bubo,  832 
Head,  contusions  of,  543 

diseases  of,  535 

gunshot-wounds  of,  555 

injuries  of,  543 

teianus,  145 
Healing  by  first  intention,  82 

by  granulation,  84 

by  second  intention,  84 

by  third  intention,  85 
Healthy  pus,  94 
Heart,  diseases  and  injuries  of,  239 

suture  of,  240 

tapping  of,  274 

wounds  and  injuries  of,  240 

-wounds,  treatment  of,  240 
Heat  as  a  germicide,  29 

forms  of,  for  use  in  inflammation,  70 

intermittent,  69 
Heberden's  nodules  or  nodosities,  427,  428 
Hectic  fever,  89,  100 
Heiman's   case  of  arthritis   from  gonorrheal 

ophthalmia,  423 
Heineke-Mikulicz  operation,  639,  674 
Helferich  method  of  treating  delayed   union 

of  fractures,  341 
Heller's  test  for  blood  in  urine,  764 
"  Helpless  eversion,"  383 
Hematemesis,  271 
Hematic  abscess,  90 
Hematocele,  840 

encysted,  of  the  cord,  F41 
of  the  testicle,  841 

parenchymatous,  841 

vaginal,  840 
Hematoid  carcinoma,  236 
Hematoma,  160 

of  dura  mater,  558 
Hematuria,  763 

renal,  764 
Hemoptysis,  271 
Hemorrhage,  258 

actual  cautery  in,  262 

acupressure  in,  262 

as  a  cause  of  shock,  162 

capillary,  treatment  of,  267 


Hemorrhage,  cerebral,  548,  549 

compression  in,  262 

concealed,  diagnosis  of,  from  shock,  163 

consecutive,  272 

constitutional  symptoms  of,  258,  259 

elevation  in,  262 

extradural,  266,  547,  548 

extrameduUary  spinal,  266 

following  lateral  lithotomy,  270 

forced  flexion  in,  263 

from  bladder,  270,  766 

from  cerebral  sinus,  266 

from  diploe,  265 

from  ear,  269 

from  femoral  vein,  266 

from  intercostal  artery,  265 

from  kidney,  270 

from  large  bowel,  271 

from  leech-bite,  269 

from  lung,  271 
treatment  of,  260 

from  mammary  artery,  265 

from  nose,  268 

from  palmar  arch,  263 

from  prostate,  270 

from  punctured  wounds,  265 

from  small  bowel,  271 

from  stomach,  271 

from  tooth  socket,  262,  266 

from  urethra,  269 

from  urinary  meatus,  262 

from  varicose  vein,  267 

from  vessels  in  bony  canal,  265 

from  wounds,  162 
arrest  of,  165 

in  abdominal  section,  267 

in  amputation,  prevention  of,  842 

in  gunshot-wounds,  171,  268 

intercurrent,  272 

intermediate,  272 

intra-abdominal,  267 

intracranial,  547 

ligation  in,  260 

pressure  in,  267 

primary  golden  rules  for  procedure  in,  263 

reaction  after,  treatment  of,  260 

reactionary,  272 

rectal,  269 

recurrent,  272 

renal,  270 

secondary, 272 
treatment  of,  273 

styptics  in,  262 

subcutaneous,  258,  269 

subdural,  548,  549 

syncope  in,  259 

torsion  in,  261 

treatment   of   constitutional  symptoms  of, 
259 

umbilical,  269 

urethral,  766 

uterine,  271 

vaginal,  271 

vesical,  270,  766 
Hemorrhagic  fever,  259 

sarcoma,  228 

ulcer,  117 
Hemorrhoids,  242,  713 

arterial,  715 

capillary,  715 

excision  of,  716 

external,  714 

internal,  714 

operative  treatment  of,  716 

ligation  of,  717 

venous,  715 
Hemostatic  agents,  260 
Hepatitis,  pain  in,  57 


INDEX. 


897 


Hepatopexy,  66i 
Hcpatotomy,  transthoracic,  103 
Hereditary  fragility  of  bones,  326 

syphilis,  185,  205.     Sec  Sy/>hilis. 
Hereditation  as  a  cause  of  tumors,  210 
Hernia,  abdominal,  699 

anatomical,  varieties  of,  712 
causes  of,  699 
congenital  inguinal,  712 
diaphragmatic,  715 
direct  inguinal,  712 
-director,  702 
encysted  inguinal,  712 
epigastric,  713 
femoral,  712 

Bassini's  operation  for,  705 
Fabricius's  operation  for,  706 
funicular.  712 
herniotomy  in,  711 
incarcerated,  706 
indirect  inguinal,  712 
infantile,  712 
inflamed,  707 

inguinal,  Bassini's  operation  for,  703 
Fowler's  operation  for,  705 
Macewen's  operation  for,  701 
into  the  foramen  of  Winslow,  713 
irreducible,  706 
Littre's,  709 
lumbar,  713 
-needles,  702 

oblique  inguinal,  herniotomy  in,  710 
obstructed,  706 
obturator,   713 
of  the  brain,  557 
of  muscles,  509 
perineal,  713 
properitoneal,  713 
pudendal,  713 
reducible,  700 
palliative  treatment  of,  700 
radical  cure  of,  705 
treatment  of,  701 
sciatic,  713 
strangulated,  707 
symptoms  of,  708 
treatment  of,  709 
umbilical,  713 

herniotomy  in,  711 
radical  cure  of,  705 
ventral,  713 
Herniotomy,  710 

Herpetic  ulcer,  differentiation  of,  from  chan- 
cer, 189 
Hetero-inoculation,  187 
Heterologous  tumors,  210 
Heurteloup's  artificial  leech,  65 
Hay,  internal  derangement  of,  470 
Hey's   amputation   at  tarsometatarsal  joint, 

852 
High  tracheotomy,  602 
Hilton's  method  of  opening  abscess,  104 
Hip  disease,  411.     See   Tuberculosis  of  hip- 
joint. 
differentiation  from  sacro-iliac  disease,  413 
from  spinal  caries,  413 
excision  of,  418 

-joint  disease,   411.     See    Tuberculosis   of 
hip-joint. 
dislocations  of,  461 
excision  of,  493 
Hodgen's  splint  for  fractures  of  the  thigh,  393 
Hoflfa's  operation,  503 

for  congenital  dislocation  of  hip,  503 
Hollow-foot,  525 
Horsley's  cyrtometer,  537,  539 

method  of  intestinal  anastomosis,  691 
of  locating  fissure  of  Rolando,  536 

57 


Hospital  gangrene,  125 
Hot-water  bag,  71 
Housemaid's  knee,  514 

treatment  of,  515 
Humerus,  dislocations  of,  448 

fracture  of,  363.     See  Fracture. 
Hunterian  chancer,  187 
Hunter's  canal,  304 

derivative  of  tuberculin,  157 

operation  for  aneurysm,  252 
Hutchinson's  knee-joint  splint,  419 

teeth,  208 
Hydatid  cysts,  238 
of  liver,  659 
of  mammary  gland,  865 
treatment  of,  239 

fremitus,  239 
Hydrargyrism,  202,  203 
Hydrarthrosis  in  gonorrheal  arthritis,  424 
Hydrencephalic  cry,  560 
Hydrencephalocele,  542 
Hydrocele,  839 

congenital,  840 

encysted,  of  the  cord,  840 

funicular,  840 

infantile,  840 

of  a  hernia,  840 
Hydrocephalus,  542 

acute,  542,  559 
Hydronephrosis,  776 

symptoms  of,  777 

treatment  of,  777 
Hydrophobia,  180 

antitoxins  of,  181 

differentiation  of,  from  lockjaw,  181 

spurious,  181 

treatment  of,  180 
Hydrophobic  tetanus,  145 
Hydrops  articuli,  407 
Hydrorrhachitis,  577 
Hyoid  bone,  fracture  of,  348 
Hyperemia,  active,  48 

passive,  49 
Hyperflexion,  brachial,  263 
Hypertrophy  of  bone,  309 

of  muscles,  505 
Hyphomycetes,  18 
Hypodermoclysis,  137 

in  erysipelas,  143 

in  hemorrhage,  259 

in  shock,  164 
Hypospadias,  830 
Hypostatic  abscess,  98 
Hysterectomy  for  uterine  hemorrhage,  271 

for  uterine  myomata.  223 
Hysteria,  traumatic,  589 
Hysterical  joint,  430 

IcHORUS  pus,  95 
Ichthyol,  69 
Ileus,  639 
Iliac  abscess,  107 

arteries,  anatomy  of,  505 

ligation  of,  305,  307 
Iliofemoral  triangle  of  Bryant,  384 
Immediate  union,  83 
Immunity,  34 
Imperforate  anus,  722 
Incarcerated  hernia,  706 
Incised  wounds,  167 

treatment  of,  167 
Incision  of  Gross  of  excision  of  hip-joint,  495 
Inclusion  theory  of  Cohnheim,  210 
Indian  operation  for  rhinoplasty,  763 
Indifferent  tissue,  53 
Indirect  cell-division,  85 
Indolent  bubo,  igo 
Induction-balance  of  Graham  Bell,  173 


898 


INDEX. 


Infantile  hernia,  712 

scurvy,  160 
Infection,  septic,  137 
Infective  myositis,  505 

sinus-thrombosis,  564 
Infected  wounds,  dressing  of,  166 

arthritis,  422 
Inferior  maxillary  bone,  fracture  of,  346 
Infiltration-anesthesia,  735 

purulent,  96 
Inflamed  hernia,  707 

joints,  rest  in,  62 
Inflammation,  48-82 

as  a  cause  of  tumor,  210 

causes  of,  56 

cell-proliferation  in,  53 

changes  in  perivascular  tissue  in,  53 

chronic,  81 

circulatory  changes  in,  48 

classification  of,  54 

constitutional  symptoms  of,  61 
treatment  of,  73 

cupping  in,  65 

definition  of,  48 

of  secretions  in,  61 

derangement  of  absorbents  in,  61 

diapedesis  in,  52 

discoloration  in,  59 

disordered  function  in,  60 

eff"usion  of  liqiior  sanguinis  in,  go 

extension  of,  55 

exudation  of  fluids  in,  51 

fever  in,  61 

formation  of  embryonic  tissue  in,  91 

from  fracture,  treatment  of,  339 

impairment  of  special  function  in,  61 

in  non-vascular  tissue,  54 

migration  in,  52 

of  antrum  of  Highmore,  596 

of  thyroid  gland,  743 

oscillation  in,  50 

pain  in,  57 

plastic,  52 

relaxation  in,  63 

retardation  of  circulation  in,  50 

serous,  51 

stagnation  of  circulation  in,  51 

swelling  in,  60 

symptoms  of,  56 

tenderness  in,  60 

terminations  of,  55,  90 

treatment  of,  62 

tumefaction  in,  60 

varieties  of,  54,  55 

vascular  and  circulatory  changes,  48 

vascular  changes  in,  48 

venesection  in,  73 
Inflammatory  fever,  61 
Ingrown  toe-nail,  742 
Inguinal  colostomy,  694 
Injury  as  a  cause  of  tumor,  210 
Innominate  artery,  anatomy  of,  291 

ligation  of,  291 
Inoculations,  protective  and  preventive,  34 
Insects,  bites  and  stings  of,  176 
Insomnia  in  syphilis,  199 
Instruments,  disinfection  of,  44 
Intercostal  neuralgia,  504 

Interdental     splint    for     fracture    of   inferior 
maxillary   bone,  348 
in  fracture  of  superior  maxillary  bone,  345 
Intermittent  heat  in  inflammation,  69 
Internal  anthrax,  179 

clot,  257 
Interpolation  in  plastic  surgery,  760 
Intertrigo  in  hereditary  syphilis,  207 
Intestinal  anastomosis,  681 
lateral,  688 


Intestinal  approximation,  693 
obstruction,  639 
acute,  639 

symptoms  of,  640 
chronic,  639 

symptoms  of,  640 
diagnosis  of,  641 

differentiation  from  other  diseases,  643 
prognosis  of,  643 
treatment  of,  643 
tuberculosis,  153 
Intestine,  malignant  tumor  of,  647 
resection  of,  681 

rupture  of,  without  external  wound,  629 
suture  of,  671 
Intoxication,  septic,  136 
Intracapsular  fracture  of  femur,  382-388 
Intracranial  hemorrhage,  547 

tumors,  565 
Intraparietal  fissure,  538 
Intubation  of  larynx,  604 

for  fracture  of  hyoid  bone,  348 
of  laryngeal  cartilages,  349 
Intussusception,  639 
operation  for,  694 
Inversion  of  leg  in  intracapsular  fracture  of 

femur,  383 
Involucrum  of  bone,  315 
lodism  from  syphilitic  treatment,  205 
Iodoform,  27 
absorption,  fever  of,  27 
emulsion,  27 
gauze,  46 
lodol,  29 

Iritis,  differentiation  of  rheumatic,  from  syph- 
ilitic, 196 
in  syphilis,  196 
Irreducible  hernia,  706 
Irrigation  of  wounds,  45,  165 
Irritable  ulcer,  116 
Irritants  in  inflammation,  72 
Ischiorectal  abscess,  721 
Italian  method  of  rhinoplasty,  763 
Itrol,  29. 

Jacob's  ulcer,  117,  235 

Janet's  method  of  treating  gonorrhea,  819 

Jerk-finger,  521 

Jobert's  suture,  673 

Johnston's  ethereal  soap,  43 

method  of  preparing  catgut,  45 
Joints,  aspiration  of,  484 

diseases  of,  406 
and  injuries  of,  409 

excision  of,  485 

floating  cartilages  in,  437 

loose  bodies  in,  437 

neuralgia  of,  431 

syphilitic  affections  of,  195 

tubercular  disease  of,  154 

tuberculosis,  154 

wounds  and  injuries  of,  432 
Jones's  nasal  splint,  343 

position  for  treatment  of  fractures,  372,  373 
Jordan's  amputation  at  hip-joint,  859 

method  of  treating  caries  of  spine,  586 
Jury-mast  of  Sayre,  587 
Juvenile  tissue,  53 

Kangaroo-tendon  sutures,  46 
Karyokinesis,  85 

Keen's  incision  for  reaching  spinal  accessory 
nerve,  520 
treatment  of  Dupuytren's  contraction,  521 
Kelly,  catheterization  of  ureters,  765 
method  of  disinfecting  operator's  hands,  43 
of  preparing  catgut,  45 
Kelly's  catheter,  765 


INDEX. 


899 


Keloid,  216 
spontaneous,  217 
treatment  of,  217 
Kidney,  abscess  of,  774 
bleeding  from,  764 
diseases  and  injuries  of,  768 
dislocated,  769 
floating  or  wandering,  768 
injuries  of,  770 
laceration  or  rupture  of,  770 
mobile,  76S 

symptoms  of,  769 
treatment  of,  770 
movable,  768 
operations  on,  779 
perforating  wounds  of,  771 
removal  of,  781 
surgical,  777 
tuberculosis  of,  778 
treatment  of,  779 
tumors  of,  768 
Kile-shaped  director,  479 
Knee-joint  disease,  418 
excision  of,  486 
subluxation  of,  470 
Knock-knee,  522 

osteotomy  for,  475 
Kocher,  experiment  of,  31 

method  of  operating  for  inguinal  hernia,  705 
Kocher's  excision  of  tongue,  619 
incision  for  nephrorrhaphy,  783 

(or  nephrotomy,  780 
method  of  circular  enterorrhaphy,  686 
of  gastro-enterostomy,  680 
of  lumbar  nephrectomy,  782 
of  pylorectomy,  676 

of  reducing  dislocations  of  shoulder-joint, 
451 
Koch's  bacillus,  4° 
circuit,  30 
lymph,  35,  157 

in  tuberculosis,  156 
tuberculin,  157 
Konig's  incision  for  nephrectomy,  781 
Kraske,  sacral  resection  of,  237 
Kraske's  operation,  720 

Krause's    method    for  removal    of  Gasserian 
ganglion,  535 
of  skin-grafting,  762 
Kreolin,  27 
Kyphosis,  583 

Lacerated  wounds,  167 
Lachrymal  bone,  fracture  of,  343 
Lacteal  cyst,  865 
Lagoria's  sign,  384 
Laminectomy,  595 

for  spinal  caries,  587 

in  extramedullary  spinal  hemorrhage,  266 
La   Mothe's   method   of   reducing   shoulder- 
joint  dislocation,  453 
Landerer's  dry  method,  43 
Langenbeck's  incision  for  abdominal  nephrec- 
tomy, 7S2 

operation,  494 
Lankester,  educated  corpuscle,  34 
Lannaiol,  29 

Lannelongue's    method    of   treating    delayed 
union  of  fractures,  341 
of  exposing  the  liver,  659 

operation  for  microcephalus,  541 
Laparotomy,  666 

for  non-suppurative  appendicitis,  668 
Larrey's  amputation  at  hip-joint,  858 

operation  for  amputation  at  shoulder,  849 
Laryngeal  cartilages,  fracture  of,  349 
Laryngotomy  for  fracture  of  laryngeal  carti- 
lages, 349 


Laryngotomy,  quick,  604 
Laryngotracheotomy,  604 
Larynx,  abscess  of,  101 

diseases  and  injuries  of,  598 
edema  of,  598 
foreign  body  in,  599 
intubation  of,  604 
operations  on,  601 
wounds  of,  598 
Lateral  curvature  of  spine,  580 

sinus,  location  of,  539 
Laudable  pus,  94 
Lawn-tennis  arm,  508 
Lead-water  and  laudanum,  68 
Leech,  artificial,  65 
Leeches  in  osteitis,  311 
Leeching,  64 
Leg,  chronic  ulcer  of,  113 

ulcer  of,  112 
Leiomyomata,  222 
Leiter's  tubes,  67 
Lemhert's  suture,  672 

for  longitudinally  torn  vein,  260,  265 
Leontiasis  ossium,  320 
Leptomeningitis,  acute,  558 

chronic,  559 
Leptothrix,  21 

Leukocytes  in  inflammation,  61 
Leukocytosis,  53 
Leukomains,  32 
Leukomata  in  syphilis,  194 
Levis's  splint,  379,  460 

Ligation  by  means  of  Hagedorn  needle,  260 
in  inflammation,  65 
in  continuity,  instruments  for,  278 
in  the  tabatiere,  282 
in  triangle  of  election,  294 

of  necessity,  294 
of  arteries  for  aneurysm,  252-25^ 
in  continuity,  27S 
incision  for,  279 
of  axillary  artery,  286-288 
in  the  first  part,  288 
in  the  third  portion,  287 
of  brachial  artery,  284-286 
at  bend  of  elbow,  285 
at  middle  of  arm,  286 
of  carotid  artery,  common,  293-295 
external,  295 
internal,  295 
of  dorsalis  pedis  arter)',  298,  299 
of  facial  artery,  297 
of  femoral  artery.  303-305 

at  apex  of  Scarpa's  triangle,  304 
in  Hunter's  canal,  305 
of  femoral  vein,  266 
of  gluteal  artery,  308 
of  iliac  arteries,  305-307 

by  abdominal  section.  3*6 
external,  by  Abernethy's  method,  306 
of  inferior  thyroid  artery,  290 
of  innominate  anery,  291 
of  lingual  artery,  296 
of  occipital  artery,  298 
of  popliteal  artery,  302 
of  pudic  artery,  internal,  308 
of  radial  artery.  281-283 
in  lower  third,  282 
in  middle  third,  283 
in  upper  third.  283 
of  sciatic  artery,  308 
of  subclavian  artery,  288,  289 
of  temporal  artery,  297 
of  thyroid  artery,  superior.  296 
of  tibial  artery,  anterior,  299-301 

posterior,  301 
of  ulnar  artery,  283,  284 
of  vertebral  artery,  288,  290 


900 


INDEX. 


Ligature,  lateral   260 
-material,  45 

subcutaneous,  for  varicocele,  275 
Ligatures,  260 
Lightning,  injuries  by,  878 
stroke,  87S 

treatment  of,  879 
Lilienthal's  probe,  173 
Line  of  demarcation,  121 
Linear  craniotomy,  577 
Lingual  artery,  ligation  of,  296 
Lipoma,  cavernous,  214 
diffuse,  214 
nevoid,  2^6 
telangiectodes,  214 
Lipomata,  214 

treatment  of,  215 
Liquor  puris,  94 

sanguinis,  effusion  of,  in  inflammation,  90 
Lisfranc's  amputation  at  shoulder-joint,  850 

at  tarsometatarsal  articulation,  850 
Lister's   abdominal  tourniquet  in  aneurysm, 
251 
cyanid  gauze,  47 
experiment,  50 

method  for  excision  of  vvfrist-joint,  491 
Listen,  amputation  at  hip-joint,  859 
modified  circular  amputation,  845 
silver-fork  deformity,  378 
Litholapaxy,  803 

in  male  children,  807 
Lithotomy,  799 
lateral,  799 
suprapubic,  800 
Lithotrites,  804,  805 
Littre's  hernia,  709 
Liver,  abscess  of,  100,  660 
displaced,  661 
hydatid  cysts  of,  659 
rupture  of,  631 
wounds  of,  658 
Lizard,  poisonous,  bite  of,  178 
Lloyd's  (Jordan)  symptom,  773 
Local  anesthesia,  734 

Locke  and  Hare,  solution  for  intravenous  in- 
jection, 277 
Lockjaw,  diagnosis  of,  from  hydrophobia,  181. 

See  Tetanus. 
Locus  minoris  resistentise,  31 
Lordosis,  583 
Lorenz's  operation  for  congenital  dislocation 

of  hip,  439,  503 
Loreta's  operation,  639,  674 
Loretin,  29 
Lumbago,  504 
Lumbar  abscess,  107 
hernia,  713 
nephrectomy,  781 
puncture,  543,  595 
Lumpy  jaw,  19.  183 
Lung,  abscess  of,  loi,  607 
diseases  and  injuries  of  605 
gangrene  of,  607 

tubercular  cavity  in,  surgical  treatment  of, 
608 
Lupus,  151 
exedens,  132 
hypertrophicus,  152 
syphilitic,  297 
vulgaris,  151 
Lusk,  method  of  skin-grafting,  760 
Lustgarten's  bacillus,  41 

in  syphilis,  185 
Luxatio  erecta,  449 
Luxations,  438.  See  Dislocations. 
Lymph  edema,  867 
effusion  of,  91,  92 
Lymphadenitis,  acute,  746 


Lymphadenitis,  chronic,  747 

infective,  746 
Lymphangiectasis,  226,  747 
Lymphangioma,  747 

circumscriptum,  747 
Lymphangiomata,  226 

treatment  of,  227 
Lymphangitis,  746 

from  septic  wounds,  175 

reticular,  746 

tubular,  746 
Lymphatic  abscess,  98 

glands,  tuberculosis  of,  154 

nerves,  226 

warts,  747 
Lymphatics,  diseases  and  injuries  of,  746 
Lymphomata,  221 

idiopathic,  221 

treatment  of,  222 
Lymphorrhea,  747 
Lymphosarcoma,  228 
Lyssa,  180.     See  Hydrophobia. 

MacCormac's  rule  for  measuring  for  a  truss, 

701 
Macewen's  method' of  compression  ot  aorta 
in  amputation  at  hip-joint,  857 
of  operating  in  mastoid  disease,  575 
operation  of  osteotomy  for  genu  valgum ,  475 

for  inguinal  hernia,  701 
triangle,  539 
Macroglossia,  226 
Macular  syphilides,  192 
Maculo-papular  syphilides,  192 
Madura  foot,  19 
Maisonneuve's  symptom,  378 

urethrotome,  826 
Malar  bone,  fracture  of,  345 
Malaria,  fever  of,  89 
Malgaigne's  hooks,  397 

method  of  treating  fracture  of  costal  carti- 
lages, 353 
Malignant  edema  following  wound,  175 
onychia,  742 
pustule,  178.     See  Anthrax. 

excision  of,  179 
tumor  of  intestine,  647 
tumors,  227,  233 
Malingering  by  persons  injured  in  accidents, 

591 
Mallet-finger,  522 
Mammary  gland,  adenocele  of,  864 

angioma  of,  864 

cancer  of,  866 

carcinoma  of,  866 

cold  abscess  of,  log 

cystic  adenoma  of,  864 

cystic  degeneration  of,  864 

cysts  of,  864 

fibro-adenoma  of,  863 

hydatid  cysts  of,  865 

involution  cysts  of,  864 

malignant  tumors  of,  865 

myxoma  of,  864 

sarcoma  of,  865 

tuberculosis  of,  108 

tumors  of,  863 
Mammillitis,  859 

Mannlicher  rifle,  velocity  of  bullet  of,  169 
Maraglinno's  antitubercular  serum,  158 
Marginal  abscess,  99 
Marie's  disease,  429 
Marine  sponges,  preparation  of,  47 
Marsupialization,  659 
Mason's  pin,  343 
Mastitis,  acute,  860 

symptoms  of,  860 

treatment  of,  861 


INDEX. 


901 


Mastitis,  chronic,  861 
lobular,  862 
treatment  of,  862 

lobular,  861 
Mastodynia,  862 

Mastoid  suppuration,  operation  for,  575 
Mattress-suture,  673 

Maunsell's  method  of  circular  enterorrhaphy, 
684 

operation  for  intussusception,  694 
Maxillary  antrum,  inflammation  and  abscess 

of,  596 
Maydl's  operation,  694 

Mcfeurney's  method  of  compressing  iliac  ar- 
tery in  amputation  at  hip-joint,  857 
of    reducing    shoulder-joint    dislocations 

with  fracture,  455 
removing  vermiform  appendix,  670 

point,  648,  652 
McCormick's  operation,  530 
McGill's  operation,  837 
McGuire's  operation,  837 
Mclntire's  splint,  394 
Mediastinum,  abscess  of,  loi 
Melanotic  cancer,  236 

sarcoma,  228 
Menard's  method  of  treating  delayed  union 
of  fractures,  341 

operation  for  spinal  caries,  5SS 
Meniere's  disease  in  syphilis,  195 
Meningitis,  tubercular,  559 
Meningocele.  541,  577 
Meningomyelocele,  577 
Mercurials,  69 
Metastasis  in  the  dissemination  of  sarcoma, 

227 
Metastatic  abscess,  99 
Metatarsalgia,  526 

MetschnikofTs  theory  of  phagocytosis,  34 
Microbes,  17,  18 

antagonistic,  36 

of  suppuration,  37 

placental  transmission  of,  36 
Microcephalus,  540 
Micrococcus,  19 

prodigiosus  antagonistic  to  anthrax,  179 

pyogenes  tenuis,  38 
Micro-organisms,  17 
Microphyta,  18 

Microscopic  test  for  blood  in  urine,  764 
Microzoaria,  18 
Micturition,  frequent,  767 
"  Middle  lobe,"  222 
INIigration  of  cells  in  inflammation,  52 
Milk  abscess,  99 
Milzbrand,  178.     See  Anthrax. 
Miners'  elbow,  515 
Mixed  infection,  36 

with  chancer  and  chancroid,  188 
Mixter's  apparatus,  761 

cannula  in  tubercular  adenitis,  155 
Mobile  kidney.  768 
Moist  gangrene,  119,  124 
Mole,  266 

excision  of,  217 
Mollities  ossium.  320.     See  Osteomalacia. 
Molluscum  fibrosum,  216 
Monococci,  20 

Monsel's  salt  in  hemorrhage  from  small  in- 
testine, 271 

solution  in  hematemesis,  271 
Monteggia's  dislocation,  467 
Moore's    dressing    for   fracture    of   clavicle, 

360 
Morbid  growths,  209-239 

Morbus  coxae,  411.     See  Tuberculosis  0/  hip- 
joint. 
senilis,  428 


Morbus  coxarius,  411.     See   Tuberculosis  0/ 

hip-joint. 
Morphea,  217 
Morris's  measurement,  385 

method  of  lumbar  nephrectomy,  781 
Mortification,  119 
Morton's  disease,  526 
Mother's  marks,  225 
Motile  bacteria,  17 
Moulds,  18 

Mouth,  cleansing  of,  45 
Mucopus,  95 

Mucous  membranes,  syphilitic  affections  of, 
194 

patches  in  syphilis,  194 
treatment  of,  203 
Mulberry  calculus,  791 
MUller's  law,  209 
Multiple  incision,  64 

puncture,  64 
Mummification,  122 

Murphy  button,  use  of,  in  gastro-enterostomy, 
68 1 
in  intestinal  anastomosis,  683 
Murri,  hydrophobia  antitoxin,  35 
Muscse  volitantes  in  hemorrhage,  259 
Muscles,  atrophy  of,  505 

contractions  of,  509 

degeneration  of,  505 

dislocation  of,  509 

healing  of,  86 

hernia  of,  509 

hypertrophy  of,  505 

ossific.ition  of,  506 

rupture  of,  508 

strain  of,  507 

tumors  of,  506 

wounds  and  contusions  of,  507 
Muscular  rheumatism,  504 
Myalgia,  504 

symptoms  of,  504 

treatment  of,  504 
Mycetoma,  19 
Myomata,  222 

intramural,  222 

submucous,  222 

subserous,  222 

treatment  of.  223 
Myositis,  infective,  505 

ossificans,  506 
Myxedema,  743 

Myxoma  of  mammary  gland,  864 
My.xomata,  220 

treatment  of,  221 
Myxosarcoma,  220,  229 

Nails,  affections  of,  in  syphilis,  195 
Nasal  bones,  fracture  of,  342 

polypi,  221 
Necessity,  triangle  of,  292 
Neck,  anatomy  of,  291 

triangles  of,  291,  293 
Necrosis,  acute,  311 

central,  315 

in  ulceration,  in 

of  bone,  314 

symptoms  of,  316 

treatment  of,  316 
Nelaton's  dislocation,  472 

line,   ascent  of   great  trochanter  above,  in 
intracapsular  fracture  of  femur,  384 

porcelain  probe,  172 
Neoplasms,  209 
Nephrectomy,  781 

abdominal,  782 

for  mobile  kidney,  770 

for  sarcoma  of  kidney,  229 

for  tuberculosis  of  kidney,  779 


902 


INDEX, 


Nephrectomy  for  wounded  kidney,  772 

for  wounds  of  kidney,  267 

in  renal  hemorrhage,  271 

lumbar,  781 

partial,  782 
Nephrolithotomy,  774,  780 
Nephropexy,  783 
Nephrorrhaphy,  783 

for  mobile  kidney,  770 
Nephrotomy,  779 
Nerve,  healing  of,  86 

inflammation  of,  527 
,  -stretching,  531 

-suture,  530 
Nerves,  contusion  of,  530 

diseases  of,  527 

operations  upon,  530 

pressure  upon,  529 

punctured  wounds  of,  530 

section  of,  528 

symptoms  of,  529 

treatment  of,  529 
Nervous  diseases  as  predisposing  to  fracture, 
326 

sclerosis  from  syphilis,  198 

syphilis,  199 
Nervousness  of  bladder,  767 
Neuber's  plan  for  treating  knee-joint  disease, 

419 
Neuralgia,  528 

intercostal,  504 

of  joints,  431 

of  stumps,  treatment  of,  528 

treatment  of,  431 
Neurasthenia,  traumatic,  589 
Neurectasy,  531 
Neurectomy,  532 

of  inferior  dental  nerves,  533 

of  infra-orbital  nerve,  532 

of  supra-orbital  nerve,  533 
Neuritis,  527 

in  syphilis,  199 
Neurofibroma,  224 
Neuromata,  224 

false,  224 

plexiform,  224 

traumatic,  224 

treatment  of,  224 
Neuroparalytic  ulcer,  117 
Neuropathic  arthritis,  429 
Neurorrhaphy,  530 
Neurotomy,  531 
Nevoid  lipoma,  226 
Nevolipoma,  214 
Nevus,  lymphatic,  226 
Nicoladoni's  operation,  524 
Nicolaier's  bacillus,  40 
Nicoll's  prostatectomy,  837 
Nipple,  cysts  of,  162 

fissure  of,  859 

prevention  of,  859 

malignant,  dermatitis  of,  863 

Paget's  disease  of,  863 

tumors  of,  862 
Nitrous-oxid  gas  as  an  anesthetic,  733 
Nitze's  catheter,  766 
Nodes,  31 
Noma,  129 

streptococcus  of,  39 

vulvae,  129 
Non-union  of  fractures,  334 
Non-vascular  tissue,  inflammation  of,  54 
Normal  salt-solution,  intravenous  injection  of, 
277 

diseases  and  injuries  of,  596 

foreign  bodies  in,  596 
Nosophen,  28 
Nucleins,  29 


Obligate-aerobic  bacterium,  23 

parasites,  19 
Obstructed  hernia,  706 
Obstruction  of  intestine,  639.     See  Intestinal 

obstruction. 
Obturator  hernia,  813 
Occipital  artery,  ligation  of,  298 

triangle,  293 
Odontomata,  219 

treatment  of,  220 
O'Dwyer's  operation,  604 
Ogston's  operation,  476 
Oidium  albicans,  18 
Omental  graft,  674 
Omphalectomy,  705 
Onychia,  742 

in  syphilis,  195 
Oophorectomy  for  uterine  myomata,  223 
Operation,  Abbe's,  623 

Adams's,  477 

Bassini's,  for  inguinal  hernia,  703 

Bigelow's,  803 

Brandt's,  of  stomach-reefing,  58i 

Cock's,  830 

Cripp's,  780 

Estlander'S;  610 

Fergusson's,  616 

for  mastoid  suppuration,  575 

for  spina  bifida,  594 

for  varicocele,  274 

for  varix  of  leg,  274 

Grant's,  478 

Halsted's,  for  cancer  of  breast,  868,  869 

Heineke-Mikulicz,  639,  674 

Hoffa's,  503 

Kraske's,  720 

Lannelongue's,  541 

Langenbeck's,  494 

Lorenz's,  503 

Loreta's,  639,  674 

Macewen's,  475 

for  inguinal  hernia,  701 

Maunsell's,  694 

Maydl's,  694 

McCormick's,  530    , 

McGiU's,  837 

O'Dwyer's,  604 

of  Fabricius  for  femoral  hernia,  706 

Ogston's,  476 

on  abdomen,  666 

on  bladder,  799 

on  larynx  and  trachea,  601 

on  skull  and  brain,  571 

on  spine,  594 

on  vascular  system,  274 

Owen's,  for  cleft  of  hard  palate,  617 

Parker's,  494 

preparations  for,  43 

Schede's,  611 

Senn's,  for  fecal  fistula,  694 

Syme's,  830 

Treve's,  483 

Van  Hook's,  783 

Volkmann's,  840 

Wheelhouse's,  830 

Whitehead's,  717 

White's,  838 
Ophthalmia,  gonorrheal,  treatment  of,  822 
Ophthalmoplegia  from  syphilis,  198 
Opisthotonos  in  tetanus,  144 
Orange  pus,  95 
Orchidectomy,  838 
Orchitis,  838 
Orrotherapy,  35 
Orthopedic  surgery,  519 
Orthotonos  in  tetanus,  145 
Oscillation  of  blood  in  inflammation,  50 
Ossification  of  muscle,  506 


INDEX. 


903 


Ossifluent  abscess,  99 
Osteitis,  309 

purulent,  313 

suppurative,  313.     See  Caries. 

symptoms  of,  310 

treatment  of,  311 

tubercular,  154,  313 
Osteo-arthritis,    462.     See    Arthritis   de/or- 

tiians. 
Osteo-arthopathic      hypertrophiante       pneu- 

mique,  429 
Osteocopic  pains  in  syphilis,  195 
Osteomalacia,  320 

symptoms  of,  32c 

treatment  of,  320 
Osteomata,  218 
Osteomyelitis,  acute  diffuse,  317 

as  a  cause  of  necrosis,  315 

chronic,  319 

of  vertebrae,  579 
Osteoperiostitis,  310 

diffuse,  311 

symptoms  of,  310 

treatment  of,  311 
Osteophytes  in  hereditary  syphilis,  207 
Osteoplastic  periostitis,  312 

resection  of  skull,  572 
Osteosarcoma,  229 
Osteotome,  475 
Osteotomy,  475 

cuneifnrm,  475,  477 

for  bent  tibia,  477 

for  faulty  ankylosis  of  hip-joint,  477 
of  knee-joint,  478 

for  genu  valgum,  475 

for  hallux  valgus,  479 

for  knock-knee,  475 

for  talipes  equinovarus,  479 

for  talipes  equinus,  480 

for  vicious  union  of  fracture,  479 

linear,  475,  477 

longitudinal,  for  osteitis,   311 

of  shaft  of  femur  below  trochanters,  478 

mallet,  475 

through  neck  of  femur,  477 
Ovaries,  removal  of,  in  osteomalacia,  320 
Overlapping  of  fragments  in  fracture,  328 
Owen's  operation  for  cleft  hard  palate,  617 

for  double  harelip,  615 
Oxycyanid  of  mercury,  29 

Pachymeningitis,  557 

externa,  557 

interna,  558 
lisemorrhagica,  558 
Paget's  abscess,  99 

disease,  234,  427.    ^^^  Arthritis  deformans . 
of  nipple,  863 
Painful  ulcer,  n6 
Palmar  abscess,  loi,  511 

pad  in  hemorrhage  from  palmar  arch,  264 
Pancreas,  cysts  of.  665 

hemorrhage  from,  664 
Pancreatitis,  acute,  664 
"  Papering  "  of  mastoid  cavity,  576 
Papillomata,23i 

treatment  of,  231 

villous,  231 
Papular  syphilides,  193 
Papulosquamous  syphilides,  193 
Para-appendicitis,  651 
Paracentesis  auriculi,  274 

pericardii,  274 

thoracis,  608 
Paralysis,  crawling,  592 
Paraphimosis  in  gonorrhea,  816 

treatment  of,  821 
Parasites,  facultative,  19 


Parasites,  obligate,  19 
Parasitic  bacteria,  19 

origin  of  tumors,  211 
Paratoloid,  157 
Paratrimma,  130 
Paresis  from  syphilis,  198 
Parker's  oblique  incision,  670 

operation,  494 
Paronychia,  513 

in  syphilis,  195 
treatment  of,  203 
Passive  hyperemia,  49 
Pasteur's  preventive  inoculations,  34,  35 

vibrione  septique,  41 
Patella,  fracture  of,  395 

wiring  of,  483 
Pelvis,  fracture  of,  355 
Penis,  amputation  of,  833 

cancer  of,  833 

fracture  of,  833 

gangrene  of,  833 

injuries  of,  810 
Peptic  ulcer  of  stomach,  636 
Perforating  ulcer,  117 
Pel  i-appendicitis,  651 
Periarteritis,  244 
Periarticular  edema,  407 
Pericardial  effusion,  240 
Pericarditis,  purulent,  treatment  of,  240 

traumatic,  240 
Pericardium,  diseases  of,  239 

tapping  of,  274 
Perineal  bruises,  810 

section,  830 

for  hemorrhage  from  prostate,  270 
Perinephric  abscess,  loi,  776 
Perinephritis,  775 
Perineum,  bruises  of,  810 
Periosteal  bridge  in  simple  fracture,  332 
Periosteum,  inflammation  of,  310,  311 

nodes  of,  311 

slitting  of,  for  osteitis,  311 
Periostitis,  310,  311 

chronic,  311 

diffuse,  311 

in  syphilis,  195 

osteoplastic,  312 

simple,  acute,  310,  311 
Peritoneal  tuberculosis,  153 
Peritoneum,  rupture  of,  627 

toilet  of,  after  celiotomy,  667 
Peritonism,  627 
Peritonitis,  653 

diffuse,  septic,  85S 

fibrinoplastic,  655 

plastic,  655 

suppurative,  656 

tubercular,  657 
Pernio,  738 

Peroxid  of  hydrogen,  27 
Pes  cavus,  525 

planus,  528 
Petit's  tourniquet,  843 
Phagedena,  129 

differentiation  of,  from  chancer,  189 

sloughing,  125 

treatment  of,  832 
Phagedenic  ulcer,  112,  117 
Phagocytes,  33 
Phagocytosis,  33 

Phenate  of  cocain  as  an  anesthetic,  735 
Phimosis,  833 

in  gonorrhea,  816 
treatment  of,  821 
Phlebectasia,  241 
Phlebectasis,  241 
Phlebitis,  240 

from  fracture,  treatment  of,  338 


904 


INDEX. 


Phlebitis,  symptoms  of,  241 

treatment  of,  241 
Phlebotomy,  275 

in  inflammation,  73 
Phlegmonous  abscess,  98 

erysipelas,  142 

suppuration,  96 
Photophobia,  6t 
Phthisis,  syphilitic,  198 

Physiological  activity  as  a  cause  of  sarcoma, 
211 

decline  as  a  cnuse  of  cancer,  211 
Pick's  table  of  dislocations  of  shoulder-joint, 

450 
Pilchei  on  treatment  of  Colles's  fracture,  380 
Piles,  242,  713.     See  Hemorrhoids. 
Pirogoff's  amputation  at  ankle-joint,  853 
Placental  transmission  of  bacteria,  36 
Piaster-of- Paris  bandage,  758 
Plastic  infiltration,  53 

inflammation,  52 

lymph,  92 

surgery,  759 
Pleura,  diseases  and  injuries  of,  605 
Pleurisy,  rest  in,  62 

tubercular,  154 
Pleuritic  effusion,  605 
Pleurodynia,  504 
Plexiform  angiomata,  226 

sarcoma,  229 
Plugging  of  nares  for  epistaxis,  268 
Pneumococcus  antagonistic  to  anthrax,  179 
Pneumotomy,  607 

for  abscess  of  lung,  611 
Pointing  of  abscess,  98 

of  pus,  95 
Points  douloureux,  58 
Poisoned  wounds,  174 
Polydactylism,  521 
Polyps,  220 

fleshy,  222 

nasal,  222 
Popliteal  artery,  ligation  of,  302 
Port- wine  stains,  226 
Postfebrile  gangrene,  131 
"  Post-operation  rise,"  83 
Postpharyngeal  abscess,  107 
Potash  soap,  29 
Pott's  disease,  583,  586 

forcible  correction  in,  587 
symptoms  of,  584 

fracture,  402 

gangrene,  120 
Poultice,  antiseptic,  166,  167 
Precentral  sulcus,  538 
Preparations  for  an  operation,  44 
Pressure  in  hemorrhage,  267 

upon  nerves,  529 
Preventive  inoculation,  34 

trephining,  551 
Primary  infection,  36 

syphilis,  186 

union,  82 
Proctotorny  for  stricture  of  rectum,  719 
Profeta's  immunity  against  syphilis,  185 
Prolapse  of  anus  and  rectum,  717 

treatment  of,  718 
Prolapsus  ani,  717 

recti,  717 
Properiioneal  hernia,  713 
Prostate  gland,   abscess  of,  from  gonorrhea, 
treatment  of,  821 
hypertrophy  of,  834 
prostatectomy  for,  837 
symptoms  of,  835 
treatment  of,  835 
Prostatectomy  for   hypertrophy  of  prostate, 
837 


Prostatic  abscess,  loi 

Prostatitis,  acute,  from  gonorrhea,  treatment 
of,  821 

chronic,  from  gonorrhea,  treatment  of,  822 
Protective  inoculations,  34 
Proteus  vulgaris,  41 
Protonuclein,  29 

as  a  wound  dressing,  166 
Pruritus  of  anus,  724 
Pieudofluctuation  of  lipoma,  214 
Psoas  abscess,  99,  107,  109 
Psoriasis  in  syphilis,  treatment  of,  203 
Psorosperm  of  Darier,  212 
Psorospermosis,  212 
Psychical  traumatism,  590 
Ptomains,  32 
Ptosis  in  syphilis,  199 

Ptyalism,  acute,  from  syphilitic  medication, 
202 

from  use  of  corrosive  sublimate,  25 
Pudic  artery,  internal,  ligation  of,  308 
Pulmonary   phthisis,    surgical   treatment   of, 
608 

tuberculosis,  153 
Pulpy  degeneration,  408 
Pulsating  goiter,  745 
Pulse  in  shock,  162 
Puncture,  bloodletting  by,  64 

lumbar,  543,  595 

multiple,  64 

of  spinal  meninges,  595 
Punctured  wounds,  167 

"  Purse-string"  suture  in  perforation  of  kid- 
ney, 771 
Purulent  infiltration,  96 

pericarditis,  240 
Pus,  "  aseptic,"  93 

-corpuscles,  94 

forms  of,  94 

microbes,  37 

-serum,  94 
Pustular  syphilides,  193 
Pyelitis,  775 
Pyelonephritis,  775 
Pyemia,  138 

arterial,  139 
Pyemic  abscess,  99 
Pylorectomy,  675 

for  cancer  of  pylorus,  237,  636 

for  pyloric  stenosis,  639 
Pyloroplasty,  674 

for  pyloric  stenosis,  639 
Pylorus,  digital  dilatation  of,  674 

excision  of,  675 

stenosis  of,  638 
Pyogenic  cocci,  20 

microbes,  37 

organisms  as  causes  of  osteomyelitis,  317 
Pyonephrosis,  777 

Quilt  suture,  673 
Quincke's  lumbar  puncture,  595 
for  hydrocephalus,  543 

Rabies,  180.     See  Hydrophobia. 
Radial  artery,  anatomy  of,  281 

incision,  491 

ligation  of,  281.     See  Ligation, 
Radiograph,  872 
Radish-fracture,  323 
Radius,  fracture  of,  375 

subluxation  of  head  of,  457 
Railway  spine,  589 
Ranula,  618 

Rattlesnake  bile  in  treating  snake-bite,  178 
Rawhide  mallet  for  osteotomy,  475 
Ray-fungus,  183 
Raynaud's  gangrene,  126 


INDEX. 


905 


Reactionary  hemorrhage,  272 
Recium,  cancer  of,  720 

cleansing  of,  44 

diseases  and  injuries,  713 

excision  of,  720 

foreign  bodies  in,  721 

gonorrhea  of,  823 

prolapse  of,  717 

stricture  of,  719 

ulcer  of,  718 

wounds  of,  721 
Recurrent  hemorrhage,  272 
Red  thrombus,  133 
Reducible  hernia,  700 
Reduction  of  fracture,  335 
Reef-knot  in  ligation,  280,  281 
Regurgitation  in  shock,  163 
Reid,  method  of  rapid  pressure  in  aneurysm, 

252 
Relaxation  in  inflammation,  63 
Reminders  in  the  causation  of  syphilis,  185 

in  intermediate  period  of  syphilis,  197 

treatment  of.  205 
Removal  of  Gasserian  ganglion,  533 
Renal  calculus,  772 
symptoms  of,  773 
treatment  of,  774 
Repair,  82 
Resection  of  intestine,  681 

of  rib,  610 

of  sacrum,  720 
Residual  abscess,  99 
Resolution  of  inflammation,  55 
Retardation  of  circulation,  50 
Retention  of  urine,  784 

from  enlarged  prostate,  treatment  of,  7S7 
from  gonorrhea,  treatment  of,  821 
Retinal  anemia  from  shock,  163 
Retinitis  in  syphilis,  196 
Retrenchment  in  plastic  surgery,  760 
Ketroclusion,  262 
Retropharyngeal  abscess,  107 
Reverdin's  method  of  skin-grafting,  760 
Rhabdomyoniala,  222 
Rheumatic  arthritis,  425 

gout,  427.     See  Arthritis  de/ortnans. 
partial,  428 
progressive,  429 

torticollis.  504 
Rheumatism,  acute,  425 

chronic.  425 

gonorrheal.  423 

muscular,  504 
Rheumatoid  arthritis,  426.     See  Arthritis  de- 

/orntans. 
Rhigolene,  anesthesia  by,  734 
Rhinoplasty,  763 
Rhoad's  apparatus,  447 
Rhodius's  case  of  lipoma,  214 
Rib,  excision  of,  499 

fracture  of.  349 

resection  of,  610 
Rickets,  158 

a  predisposing  cause  of  fracture,  326 

congenital,  1^8 

treatment  of,  159 
Ricord,  glandulae  Pleiades,  190 
Ricord's  method  of  amputating  penis,  833 
Rider's  leg,  508 
Rifle  bullets,  wounds  by,  169 
Ri-^us  sardonicus  in  tetanus,  144 
Robson's  treatment  of  spina  bifida,  578 
Robson's  decalcified  bone  bobbin,  685 

operation  for  meningocele,  542 
Rodent  nicer,  117,  235 
Roger  and  Charrin's  serum.  142 
Rolando's  fissure,  location  of.  535 
Rontgen  rays,  employment  of,  871 


Rontgen  rays  in  diagnosing  fractures,  231 
Rosenthal's  test  for  blood  in  urine,  764 
Roseola  of  syphilis,  192 
Round-cell  sarcoma,  228 
Rubber-dam  in  dressings,  47,  166 
Run-around,  742 
Rupia,  193 

in  tertiary  syphilis,  197 
Rupture,  699.     See  Hernia. 

of  abdominal  wall  from  contusion,  627 

of  bile-ducts,  631 

of  gall-bladder,  631 

of  intestine  without  external  wound,  629 

of  liver,  631 

of  muscle,  508 

of  peritoneum,  627 

of  a  sinus,  549 

of  spleen, 631, 665 

of  stomach  without  external  wound,  62S 

of  tendons,  510 

Sabanejeff's  amputation  of  leg,  856 
Saccharorayccs,  18 

capillitii.  iS 
Sacro-iliac  disease,  410 
Sacrum,  fracture  of,  357 

resection  of,  720 
Saddle-back,  583 
Salicylic  acid,  29 
Salivation  from  mercurial  treatment  of  syph- 

ills,  202 
Salol,  29 

Sanderson,  definition  of  inflammation,  48 
Sanious  pus,  95 
Sapremia,  136 
Saprophytes,  19 
Sarcina,  20 
Sarcocele,  syphilitic,  196 

treatment  of,  203 
Sarcoma,  alveolar,  228 

black,  228 

clinical,  varieties  of,  228 

giant-cell,  228 

hemorrhagic,  229 

melanotic,  22S 

mixed-cell,  228 

myeloid,  228 

of  bone,  309 

of  mammary-  gland,  865 

plexiform,  229 

round-cell,  228 

spindle-cell,  228 
Sarcomata,  227 

species  of,  228 

treatment  of,  229 
Sardonic  smile  in  tetanus,  144 
Saviard,  aneurj-sm-needle  ot,  279 
Sayre's  adhesive-plaster  dressing,  360 

extension  for  knee-joint  disease,  419 

knee  splint.  418,  419 

jury-mast,  587 

long  splint,  416 

plaster-of-Paris  jacket,  587 
Scalds,  736 

of  glottis,  737 
Scalp,  diseases  of,  539 

-wounds,  543 
Scapul.1,  excision  of,  499 

fracture  of,  362.     See  Fracture. 
Scarification,  64 
Scarlet  fever,  surgical,  90 
Scarpa's  triangle,  303 
Schede's  method  of  treating  varix  of  leg,  274 

operation,  611 
Schizomycetes,  18 
Schleich's  fluid  in  operation  for  varicocele,  275 

new  general  anesthetic,  733 

solutions  for  infiltration-anesthesia,  735 


go6 


INDEX. 


Sciatic  artery,  ligation  of,  308 

nerve,  stretching  of,  532 
Scirrhous  carcinoma.  235 
Scirrhus  of  mammary  gland,  866 
Scolices  of  echinococcus,  239 
Scoliosis,  580 

symptoms  of,  581 

treatment  of,  581 
Scorbutic  ulcer,  118 
Scorpion,  sting  of,  176 
Scotch  douche,  69 
Scrofula,  151 
Scrofulodermata,  152 
Scrofulous  pus,  95 
Scurvy,  159 

infantile,  160 

treatment  of,  160 
Sebaceous  cysts,  237 
Second  intention,, healing  by,  84 
Secondary  hemorrhage,  272 
treatment  of,  273 

infection,  36 

syphilis,  191 
Section  of  nerves,  528 
Sedative  poultice,  71 
Sedillot's  leg-amputation,  854 
Segmentation  of  bacteria,  21 
Selva's  thumb  bandage,  750 
Seminal  vesiculitis,  834 
Senile  gangrene,  121 

Senn's  apparatus  for  intracapsular  fracture  of 
femur,  388 

bone  ferrule,  481,  483 

plate  in  lateral  intestinal  anastomosis,  688 

decalcified  bone-chips,  48 

hydrogen-gas  test,  628,  629 

method  for  excision  of  shoulder-joint,  490 
of  gastro-enterostomy,  680 
of  intestinal  anastomosis,  682 
of  making.fistula  in  gastrotomy,  679 

operation  for  fecal  fistula,  694 

package  of  wound-dressing  for  soldiers,  174 

probe  for  gunshot-wounds  of  head,  556 
Separation  of  lower  radial  epiphysis,  370 
Sepsis,  136 
Septic  gangrene,  119 

infection,  137 

intoxication,  136 

wounds,  175 
Septicemia,  136 

true,  137 
Sequestrotomy,  316 
Sequestrum,  315 
Serous  inflammation,  51 

pus,  95 
Serpiginous  ulcers  in  tertiary  syphilis,  197 
Serum-therapy,  35 

Sheild,  method  of  operating  on  mastoid  dis- 
ease, 575 
Shirt-stud  abscess,  105 
Shock,  diagnosis  of,  163 

from  gunshot-wounds,  172 

from  wounds,  162 

operation  during,  164 

symptoms  of,  162,  163 

treatment  of,  163 
Shoulder-cap  in  fracture  of  humerus,  364,  366 

-joint  disease,  420 
dislocation  of,  448 

excision  of,  487 
Signorini  tourniquets  in   treatment  of  aneu- 
rysm, 251 
Silicate  of  sodium  bandage,  759 
Silk  sutures,  preparation  of,  46 
Silkworm-gut,  46 
Silver,  28 

-fork  deformity,  378 

nitrate,  69 


Silver-wire  sutures,  46 
Sinus,  118 

-thrombosis,  infective,  564 
Skey's  method  of  amputating  foot,  852 
Skiagraph,  872 

for  locating  bullets,  173 

of  fractured  bones,  331 

method  of  taking,  873 
Skiagraphy,  871 
Skin  and  nails,  diseases  of,  739 
Skin-grafting,  760 

in  treatment  of  tuberculosis,  156 

Krause's  method  of,  762 

Reverdin's  method  of,  760 

'J'hiersch's  method  of,  761 
Skull,  fractures  of,  599 

osteoplastic  resection  of,  572 
Sloughing,  129 

from  fracture,  treatment  of,  337 
Smith's  (Henry  H.)  method  of  treating  dislo- 
cations of  shoulder-joint,  452 
Smith's  anterior  splint  for  fracture  of  femur. 

Snake-bites,  177 

constitutional  treatment  of,  178 

symptoms  of,  177 

treatment  of,  177 
Snuff-box,  anatomical,  282 
Soft  palate,  suture  of,  616 
Sorbefacients,  68 

Souchon's  apparatus  for  administering  chloro- 
form, 728 
Spectroscopic  test  for  blood,  763 
Sphacelin,  119 

Spheroidal-celled  carcinomata,  235 
Spica  bandage,  748 

of  groin,  754 

of  instep,  751 

of  shoulder,  754 

of  thumb,  750 
Spiders,  bites  of,  176 
Spina  bifida,  577 

operations  for,  594 
treatment  of,  578 
Spinal  caries,  583 
Spinal  cord,  compression  of,  592 
concussion  of,  591 
contusion  of,  591 
curvatures,  580 
wounds  of,  591 
Spine,  congenital  deformities  of,  577 

fractures  and  dislocations  of,  592 

operations  on,  594 

surgery  of,  577 

tumors  of,  578 
Spirillum,  19 
Spleen,  abscess  of,  665 

rupture  of,  631,  665 

wandering,  665  • 

wounds  of,  665 
Splenectomy,  666,  698 

for  wounds  of  spleen,  267 
Splenic  fever,  168.     See  Anthrax. 
Splenopexy,  666 
Splint,  Agnew's,  396 

anterior   angular,  in   fractures  near  elbow- 
joint,  371 

Bond's,  379.  380 

Dupuytren,  403 

Fox's,  for  clavicle,  380 

Gordon's  pistol-shaped,  379 

Hodgen's,  393 

internal  angular,  365 

in  fracture  of  humerus,  368 

Jones's  nasal,  343 

Levis's,  379,  460 

Mclntyre's,  394 

Sayre's,  416 


INDEX. 


907 


Splint,  Sayre's,  for  knee,  418 

Thomas's,  416 

Watson's  swing-splint.  496 
Splinter-fracture,  322 
Spondylitis,  583 

deformans,  428 
Sponges,  gauze,  45 

marine,  perforation  of,  47 
Spongiopilin,   71 
Spontaneous  keloid,  217 
Spores,  21 
Sporulation,  22 
Sprain,  432 

diagnosis  of,  433 

fracture,  433 

prognosis  of,  433 

symptoms  of,  433 

treatment  of,  434 
Springfield  rifle,  velocity  of  bullet  of,  169 
Spurious  hydrophophia,  181 
Ssabanejew-Frank  operation  for  gastrostomy, 

679 
St.  Anthony's  fire.     See  Erysipelas. 
Stagnation  in  inflammation,  51 
Staphylococci,  20 
Staphylococcus  cereus  flavus,  38 

epidermidis  albus,  38 

flavescens,  38 

pyogenes  albus,  38 
aureus,  20,  37 

a  cause  of  acute  diffuse  osteomyelitis, 

317 
as  a  cause  of  boils,  739 
citreus,  38 
Staphylorrhaphy,  616 
Stasis  of  blood  in  inflammation,  51 
Stay-knot,  281 
Stenosis  of  cardia,  637 

of  pylorus,  638 
Stercoraceous  abscess,  99 
Sterilized  gauze,  46 

Sternal  symptom  in  carcinoma  of  breast,  867 
Sternberg's  theory  of  phagocytosis,  34 
Sternum,  fracture  of,  353 
Stings  of  bees  and  wasps,   176 

of  insects,  176 
Stitch-abscess  in  surgical  fever,  8g 
Stomach,  cancer  of,  634 

-orifices,  cicatricial  stenosis  of,  637 
peptic  ulcer  of,  636 
-reefing,  681 

rupture  of,  without  external  wound,  628 
Stone  in  bladder,  790.  See  Vesical  calculus. 

operation  for,  in  women,  807 
Strain-fracture,  322 
of  a  muscle,  507 
Strangulated  hernia,  707.     See  Hernia. 
Strangulation  of  intestine,  639 
Streptobacilli,  21 
Streptococci,  20 
Streptococcus  articulorum,  39 
of  erysipelas,  38,  140 

antagonistic  to  anthrax,  179 
pyogenes,  38 

as  a  cause  of  osteomyelitis,  317 
septicus,  38 
Stretching  of  sciatic  nerve,  532 
Stricture  of  esophagus,  620 
cancerous,  623 
cicatricial  or  fibrous,  620 
treatment  of,  622 
of  rectum,  719 
of  urethra,  S23 

symptoms  and  results  of,  824 
treatment  of,  825 
organic,  catheterization  in,  785 
spasmodic,  catheterization  in,  786 
Stromeyer's  anterior  angular  splint,  421 


Strongylus  armatus   as  a  cause  of  aneurysm 

in  horses,   248 
Strumous  abscess,  98 

joint,  408 
Struve's  test  for  blood  in  urine,  764 
Stupe,  70 

turpentine,  70 
Styptics  in  hemorrhage,  262 
Subastragaloid  dislocation,  473 
Subclavian  artery,  anatomy  of,  288 
ligation  of,  288,  289 

triangle,  293 
Subcutaneous   drilling  and   scraping   for  de- 
layed union  of  fractures,  341 

ligature  lor  varicocele,  225 

tubercle,  painful,  216 
Subcuticidar  suture,  Halsted's,  42 
Subdural  abscess,  560 

hemorrhage,  548,  549 
Subluxation  of  head  of  radius,  457 

of  knee-joint,  470 

of  shoulder-joint,  450 
Submaxillary  triangle,  292 
Submental  triangle,  292 
Subphrenic  abscess,  100,  657 
Suggillation,  160 
Sunburn,  treatment  of,  737 
Superficial  abscess,  99 
Superior  longitudinal  sinus,  location  of,  539 

maxillary  bone,  fracture  of,  344 
Supernumerary  digits,  521 
Suppuration,  93 

phlegmonous,  96 

symptoms  of,  95 
Suppurative  fever,  89 

thecitis,  loi 
Surgery  of  the  respiratory  organs,  596 

of  the  spine,  577 
Surgical  fevers,  87,  88 

kidney,  777 

scarlet  fever,  go 
Suture  a  distance,  531 

continuous,  46 
of  dura,  575 

Cushing's  right-angled,  673 

Czerny-Lembert,  673 

Dupuytren's,  673 

Gussenbauer's,  673 

Halsted's,  42 
mattress  or  quilt,  673 

interrupted,  of  scalp,  575 

Jobert's,  673 

Lembert's,  672 

of  intestine,  671 

Wolfler's,  674 
Suturing  of  annular  ligament  of  wrist,  519 
Swedish  leech,  63 
Sweet's  apparatus  for  locating  foreign  bodies 

by  Jf-rays,  876 
Swelling  in  inflammation,  60 
Sylvius'  fissure,  location  of,  537 
Syme's  amputation  at  ankle-joint,  853 
for  ankle-joint  disease,  420 

incision  for  excision  of  scapula,  499 

method  of  amputating  leg,  855 

operation  of  external  urethrotomy,  830 

staff.  830 
Symmetrical  gangrene.  126 
Sympathetic  abscess,  99 

fever,  61 
Symptomatic  fever,  61 
Syncope,  local,  126 
Syndactylism,  521 
Synovitis,  406 

acute,  simple,  406 

symptoms  of,  406 
treatment  of,  407 

chronic,  407 


9o8 


INDEX. 


Synovitis,  chronic,  symptoms  of,  408 

treatment  of,  408 
in  hereditary  syphilis,  207 
in  syphilis,  195 
pannous,  409 
traumatic,  407 
Syphilide,  diagnosis  between  secondary  and 
tertiary,  194 
macular,  192 
maculopapular,  192 
tubercular,  194 
Syphilides,  191 
papular,  193 
papulosquamous,  193 
pustular,  193 
Syphilis,  184-209 
acquired,  185 
affections  of  bones  in,  195 

of  brain  in,  199 

of  ear  in,  195 

of  eye  in,  196 

of  hair  in,  195 

of  joints  in,  195 

of  mucous  membranes  in,  194 

of  nails  in,  195 

of  testes  in,  196 
albuminuria  in,  199 
alopecia  in,  195 

amyloid  degeneration  from,  198 
arteritis  in,  196 
ataxia  in,  19S 
bacilius  of,  41 
baldness  in,  195 
bubo  of,  190 

calomel  fumigation  in,  201 
choroiditis  in,  196 
condylomata  of,  194 
congestion  of  viscera  in,  197 
definition  of,  184 
diagnosis  between  secondary  and  tertiary 

lesions  of,  194 
endarteritis  in,  196 
epididymitis  in,  196 
epilepsy  in,  199 
general,  190 
hereditary,  185,  205 

dactylitis  in,  207 

diagnosis  of,  207 

evidences  of,  207 

Hutchinson  teeth  in,  208 

interstitial  keratitis  in,  207 

intertrigo  in,  207 

snuffles  in,  207 

treatment  of,  208 

Virchow's  sign  in,  207 
immunity  from,  185 
infection  in  utero,  206 
initial  lesions,  187 
insomnia  in,  199 
intermediary  period  of,  196 
iritis  in,  196 

Meniere's  disease  in,  195 
mixed  infection  of  chancer  and  chancroid, 

1 38 
mucous  patches  in,  194 
natiform  skull  in,  207 
nervous,  199 
neuritis  in,  199 

obliterative  endarteritis  in,  196,  199 
onychia  in,  195 
ophthalmoplegia  in,  198 
osteophytes  in,  207 
palmar  psoriasis  in,  196 
paronychia  in,  195 
periostitis  in,  195 
phthisis  in,  198 
primary,  186 
ptosis  in,  199 


Syphilis,  reminders,  185,  ig6 
retinitis  in,  196 
rules  of  inheritance  of,  206 
salivation  from  mercurial  treatment  of,  220 
secondary, 191 
skin  lesions  in,  191 

treatment  of,  204 
stages  of,  186 
synovitis  in,  19s 
tertiary,  197 
gumma  in,  197 
rupia  in,  197 

serpiginous  ulcers  in,  197 
skin  eruptions  in,  197 
various  lesions  of,  198 
thrombosis  in,  196 
transmitted  congenital,  205 
transmission  of,  185 
treatment  of,  in  primary  stage,  199 
in  secondary  stage,  200 
of  complications  in  the  secondary  stage 
202 
in  tertiary  stage,  205 
visceral,  198 
warts  of,  194 
Syphilitic  abscess,  99 
bubo,  190 
eruptions,  191 

forms  of,  igi-194 
fever,  191 
erythema,  192 
maculae,  192 
roseala,  192 
sarcocele,  196 
ulcers,  197 
warts,  194 
Syphilodermata,  191 
Syringomyelia   as   a   cause  of  brittleness  of 

bones,  327 
Syringomyelocele,  577 
Swain,  method  of  treating  ankylosis,  436 
Szumann's  solution  for  intravenous  injection, 
277 

Tabatiere  anatomique,  282  ^ 

ligation  of  radial  artery  in,  282 
Tabetic  arthropathy,  429 
Tache  cerebrale,  560 
Taenia  echinococcus,  238 
Tagliacotian  method  of  rhinoplasty,  763 
Talipes,  523 

calcaneo-valgus,  524 

calcaneo-varus,  524 

calcaneus,   523 

equino-valgus,  524 

equino-varus,  524 
osteotomy  for,  479 

equinus,  523 

osteotomy  for,  580 

treatment  of,  524 

valgus,  523,  524 

varus.  523,  524 
Tapping  in  edema,  91 

of  the  heart-cavity,  274 

of  pericardial  sac,  274 
Tarantula,  bite  of,  176 
T-bandage  of  perineum,  758 
Teale's  amputation  through  forearm,  848 

flap  in  amputation  of  thigh,  S56 

method  of  amputating  the  arm,  849 
of  amputating  the  leg,  854 
Telangiectasis,  225 
Telangiectatic  carcinoma,  236 
Telephonic  probe,  Girdner's,  173 
Temperature  after  wounds  as  a  danger-signal, 
167 

in  shock,  162 
Temporal  artery,  ligation  of,  297 


INDEX. 


909 


Tendon,  healing  of,  86 

-lengthening,  518 

suture,  518 
Tendons,  dislocation  of,  509 

rupture  of,  510 

wounds  of,  510 
Tenosynovitis,  510 
Tenotomy,  516 

of  tendo  Achillis,  516 

of  tendons  of  peroneus  longus  and  brevis, 
517 

of  tendon  of  tibialis  amicus,  517 
of  tibialis  posticus,  517 
Terminations  of  inflammation,  90 
Terrier's  treatment  of  hammer-toe,  526 
Tertiary  syphilis,  197.     See  Syphilis. 

syphilitic  eruptions,  197 
Testicle   excision  of,  839 

malplaced,  838 

retained,  838 

syphilitic  affections  of,  196 
Tetanus,  144 

antitoxin,  148 

cephalic,  145 

chronic,  145 

diagnosis  of,  145 

head,  145 

hydrophobic,  145 

symptoms  of,  144 

table  of  differential  diagnosis  for,  146 

treatment  oT,  147 
Tetracocci,  20 
T-fracture  of  humerus,  371 
Thecal  abscess,  99 
Thecitis,  510 

acute,  510 
symptoms  of,  510 
treatment  of,  510 

chronic,  511 

treatment  of,  511 

suppurative,  loi 
Thiersch's  method  of  skin-grafting,  361 
Thigh,  amputation  of,  216 
Third  intention,  healing  by,  85 
Thomas's  splint,  416 

Thompson's  diagnostic  questions  in  diseases 
of  urinary  organs,  767 

divulsor,  826 

evacuator,  805 

lithotrite,  804 

vesical  forceps,  8og 
Thoracoplasty.  610 
Thoracotomy,  609 
Thrombo-arteritis,  133 
Thrombophlebitis,  133,  241 

treatment  of,  241 
Thrombiisis.  133 

in  syphilis,  197 

symptoms  of,  133 

treatment  of,  133 
Thrombus,  antemortem,  133 

causes  of,  132 

red, 133 

white,  133 
Thrush,  18 

Thumb,  amputation  of.  848 
Thymol,  29 
Thyroid  artery,  inferior,  ligation  of,  290 

extract  in  treatment  of  fibromata,  217 
in  treatment  of  goiter,  744 

gland,  atrophy  of,  743 
congestion  of,  743 
diseases  and  injuries  of,  743 
inflammation  of,  743 
wounds  of.  743 
Thyrotomy.  601 
Tibia,  fracture  of,  400 
Tibial  artery,  anterior,  ligation  of,  299-301 


Tibial  artery,  posterior,  ligation  of,  301 
Tinnitus  aurium.6i 

in  hemorrhage,  259 
Toe-nail,  ingrown,  742 
Toes,  amputation  of,  850 
Tongue,  complete  removal  of,  619 

partial  removal  of,  618 

-lie,  operation  for,  618 
Torpid  shock,  162 
Torsion  in  hemorrhage,  261 
Torsoclusion,  262 
Torticollis,  519 

congenital,  520 

rheumatic,  504 

symptoms  of,  520 

spasmodic,  520 

treatment  of,  520 
Tourniquet,  843 
Toxalbumins,  32 
Toxins,  51 
Trachea,  foreign  bodies  in,  600 

operations  on,  601 

wounds  and  injuries  of,  598 
Tracheotomy,  601 

for  fracture  of  hyoid  bone,  348 

for  fracture  of  laryngeal  cartilages,  349 

high,  602 
Transfixion.  262 

amputation  by,  846 
Transfusion,  arterial,  278 

of  blood,  276 

of  saline  fluid,  277 
Transthoracic  hepatotomy,  103 
Traumatic  carditis,  240 

dislocations,  438.     See  Dislocations. 

fever,  85. 

hysteria,  589 

inflammation  of  brain  and  its  membranes 
557 

neurastlienia,  589 

pericarditis,  240 
Traumatism,  psychical,  590 
Trendelenberg  on  method  of  treating  varix  of 
the  leg,  274 

position,  667 
Trephining,  571 

in  extradural  hemorrhage,  266 

of  bone  for  abscess,  212 

the  frontal  sinus,  573 
Treves's  "  dangerous  area,"  540 

method  of  amputating  penis,  833 
of  excision  of  scapula,  499 

operation,  483 
Triangle,  inferior  carotid,  292 

occipital,  293 

of  election,  292 
ligation  in,  294 

of  necessity,  292 
ligation  in,  294 

of  the  neck, 291 
anterior,  291 
posterior,  292 

Scarpa's,  303 

subclavian,  293 

submaxillary,  292 

submental,  292 

superior  carotid,  292 
Triangular  sling,  375 
Trichiniasis,  506 
Trichinosis,  506 
Trichlorid  of  iodin,  29 
Trigger-finger,  521 

trentinent  of,  522 
Tripper,  815.     See  Gonorrhea . 
Trismus,  145 

nascentium  or  neonatorum,  143 
Trophic  ulcer,  117 
Tropical  abscess,  99 


9IO 


INDEX. 


Truss  for  reducible  hernia,  701 
Tubercle,  140 
anatomical,  152 
bacillus  of,  149 
caseation  of,  149 
of  bone,  309 
Tubercular  abscess,  98,  99,  105 
adenitis,  154 
arthritis,  408 
disease  of  bone,  154 

of  joints,  154 
gummata,  152 
meningitis,  559 
osteitis,  154 
pleurisy,  154 
syphilides,  194 
Tuberculin,  Koch's,  157 
Tuberculosis,  148 
bacillus  of,  149 
diagnosis  of,  155 
intestinal,  153 
of  alimentary  canal,  153 
of  bone,  detection  of,  by  A'-rays,  877 
of  hip-joint,  411 

complications  of,  414 

diagnosis  of,  412 

differentiation   of,   from    sacro-iliac    dis- 
ease, 413 
from  spinal  caries,  413 

prognosis  of,  414 

symptoms  of,  411 

treatment  of,  415 
of  kidney,  778 

treatment  of  779 
of  lymphatic  glands,  154 
of  mammary  gland,  108 
of  sacro-iliac  joint,  410 
of  skin,  151 
of  special  joints,  410 
of  subcutaneous  tissue,  152 
peritoneal,  153 
prognosis  of,  155 
pulmonary,  153 
treatment  of,  155 
Tuffier   method  of  exploring  for   abscess   of 

lung,  612 
Tuffnell's  plan  for  treating  aneurysm,  250 

tourniquet  in  aneurysm,  251 
Tumors,  209-239 
causes  of,  210 
classes  of,  209 
classification  of,  213 
connective-tissue,  innocent,  214 
fibro-fatty,  214 

hereditation  as  a  cause  of,  210 
heterologous,  210 
innocent  epithelial,  231 
intracranial,  565 
malignant  and  benign,  213 

connective-tissue,  227 

epithelial,  233 
of  the  bladder,  798 
of  bone,  309 
of  brain,  565-569 

treatment  of,  567 
of  cerebellum,  567 
of  corpus  striatum,  566 
of  intestine,  malignant,  647 
of  kidney,  768 
of  mammary  gland,  863 

malignant,  865 
of  the  medulla,  567 
of  muscles,  506 
of  nipple,  863 
of  occipital  lobe,  566 
of  parieto-occipital  lobe,  506 
of  pons,  567 
of  prefrontal  region,  566 


Tumors  of  spine,  578 

of  the  temporosphenoidal  lobe,  566 

parasitic,  origin  of,  211 
Turpentine  stupe,  70 
Tympanitic  abscess,  98 
Typhoid  arthritis,  422,  423 

bacillus  as  a  cause  of  arthritis,  422 

fever,  bacillus  of,  41 

Ulcer,  iiq 

callous,  117 

classification  of,  iii 

exuberant,  116 

fungous,  116 

gummatous,  in  tertiary  syphilis,  198 

healing  of,  87 

healthy,  116 

hemorrhagic,  117 

Jacobs',  117,  235 

neuroparalytic,  117 

of  bowel,  646 

of  leg,  112 
acute,  n2 
chronic,  113 

complications  of,  115 

of  rectum,  718 

of  stomach,  peptic,  636 

perforating,  117 

phagedenic,  112,  117 

rodent,  117,  235 

scorbutic,  118 

serpiginous,  in  tertiary  syphilis,  197 

syphilitic,  197 

varicose,  116 

varieties  of,  116 
Ulceration,  no 

Ulna,  fracture  of,  373.     See  Fracture . 
Ulnar  artery,  anatomy  of,  283 
ligation  of,  283,  284 

incision,  492 
Umbilical  hernia,  713.     See  Hernia. 
Union,  delayed,  treatment  of,  341 

fibrous,  333 

immediate,  83 

of  fractures,  delayed,  334 
membranous,  334 
vicious,  treatment  of,  341 

primary,  82 
Unity  theory  of  syphilitic  infection,  187 
Uranoplasty,  616 
Ureter,  diseases  and  injuries  of,  768 

operations  on,  779 

wounds  of,  172 
Uretero-ureterostomy,  783 
Urethra,  foreign  bodies  in,  813 

inflammation  of,  814 

stricture  of,  823 

wounds  of.  Bid 
Urethral  catarrh,  chronic,  817 

discharges,  chronic,  treatment  of,  822 

fever,  829 
Urethritis,  814 

eczeraatous,  815 

gouty,  815 

simple,  814 

specific,  815.     See  Gonorrhea. 

traumatic,  814 

tubercular,  815 
Ureterolithotomy,  783 
Urethrotome,  Gross's,  826 

Maisonneuve's,  826 
Urethrotomy,  external,  830 

internal,  826 
Urinary  abscess,  99 
Urine,  retention  of,  784 
symptoms  of,  785 
treatment  of,  785 
Uterine  fibroid,  216,  222 


INDEX. 


911 


Vagina,  cleansing  of,  44 

Valentine's  method  of  irrigation  for  gonorrhea, 

819 
Valleix's  points  douloureux,  58 
Valsalva,  treatment  of  aneurysm,  250 
Van  Hacker's  method  of  gastrostomy,  679 
Van  Hook's  method  of   treating  wounds  of 
ureter,  772 

operation,  783 
Varicocele,  242,  841 

open  operation  for,  274 

subcutaneous  ligature  for,  275 
Varicose  aneurysm,  255 

lymphatics,  747 

ulcer,  116 

veins,  241 
Varix,  241 

aneurysmal,  255 

of  leg,  operation  for,  274 

treatment  of,  243 
Vascular  system,  operations  on,  274 
Veins,  inflammation  of,  240 

wounds  of,  258 
Velpeau's  bandage,  755 

in  forward  dislocation  of  clavicle,  446 
in  fracture  of  clavicle,  359 

rule,  533 
Vense  comites,  2S0 

Venereal  catarrh,  815.     See  Gonorrhea. 
Venesection,  275 

in  inflammation,  73 
Ventral  hernia,  713 
Verminous  abscess, 99 
Verruca  necrogenica,  152 
Vertebral  artery,  anatomy  of,  289 

ligation  of,  289 
Vesical  calculus,  790 
composition  of,  791 
crushing  of,  803 
symptoms  of,  792 
treatment  of,  793 
Vicious  union,  treatment  of,  341 
Virchow's  disease,  320 

law,  210 

sign,  207 
Viscera,  congestion  of,  in  syphilis,  197 
Visceral  syphilis,  198 
Volkmann's  limit,  868 

membrane,  106 

operation,  840 
Vnlvulu'^,  639 
Vomiting  in  shock,  163 
Von  Graefe's  sign,  745 

Von    Zeissl,   formula  for    treatment    of  acute 
cystitis,  795 

Wagner's   osteoplastic     resection    of   skull, 

572 
Wandering  abscess,  98 

kidney,  768 

spleen,  665 
Wardrop's  operation  for  aneurysm,  254 
Warts,  231 

in  syphilis,  194 

lymphatic,  747 
Wasps,  stings  of,  176 
Water-bath  in  inflammation,  71 

on  the  brain,  559 
Watson's  plaster-of-Paris  swing  splint,  496 
Weavers'  bottom,  515 
Webbed  fingers,  521 
Weir,    method     of     disinfecting     operator's 

hands,   43 
Wens,  238 
Wet  cold  in  inflammation,  65 

cups,  65 
Wheelhouse's  operation  of  perineal  urethrot- 
omy, 830 


White  swelling,  154,  408,  418 

thrombus,  133 
White's  division  of  syphilitic  periods,  186 

operation  of  bilateral  orchidectomy,  838 
for  myoma  of  prostate,  223 

rule  for  treating  tertiary  syphilis,  205 
Whitehead's  operation,  717 

for  removal  of  tongue,  620 
Whitlow,  512.     See  Felon. 
Wiring  of  bones  for  ununited  fracture,  483 

of  fractured  patella,  397 

of  fractures,  336 

of  ununited  fracture  of  patella,  483 
Witzel's  method  of  gastrostomy,  678 
Wladimiroff-Mikulicz  operation,  420 
Wolfler's  method  of  gastro-enterostomy,  680 

suture,  674 
Wool-sac  cocci,  20 

-sorters'  disease,  178.     See  Charhon. 
Wounds,  161 

by  cannon-balls,  171 

by  small  shot,  171 

cleansing  of,  165 

closure  of,  166 

complications  of,  167 

constitutional  treatment  of,  166 

contused,  167 
of  arteries,  257 

dissection  of,  175 

drainage  of,  166 

dressing  of,  166 

gunshot-,  168 

amputation  for,  174 
dressing  of,  174 
of  arteries,  258 

incised,  167 
of  arteries,  257 

irrigation  of,  165 

lacerated, 167 
of  arteries,  258 

local,  phenomena  of,  162 

of  abdominal  wall,  632 

of  arteries,  257 

of  brain,  554 

of  chest,  606 

of  heart,  240 

of  kidney,  770 

of  larynx,  598 

of  liver,  658 

of  mucous  membranes,  184 

of  rectum,  721 

of  spleen,  665 
I      of  thyroid  gland,  743 

of  ureter,  772 

of  veins,  258 

poisoned,  174 

punctured,  167 
of  arteries,  258 

septic,  175 

treatment  of,  165 
Wrist,  dislocation  of,  458 

-joint  disease,  421 
excision  of,  491 
Wry-neck,  519.     See  Torticollis. 
Wyeth's  apparatus  for  hip-disease,  416 

bloodless  amputation  at  hip-joint,  857 

A'-RAY  apparatus  in  diagnosticating  fractures, 

330.  331 
"  burn,"  874 
employment  of,  871 
for  discovery  of  foreign  bodies  in  esophagus, 

625 
value  of,  in  surgery,  874 

Yeasts,  i8 

Zooglea,  20 


CATALOGUE 

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No.   925   WALNUT   STREET,   PHILADELPHIA. 


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Money  may  be  sent  at  the  risk  of  the  publisher  in  either  of  the  following  ways : 
A  post-office  money  order,  an  express  money  order,  a  bank  check,  and  in  a  registered, 
letter.    Money  sent  in  any  other  way  is  at  the  risk  of  the  sender. 


See  pages  30,  31,  for  a  List  of  Contents  classified  according  to  subjects. 

LATEST  PUBLICATIONS. 

Amer.Text-Book  of  Genito-Urinary  and  Skin  Diseases.  Page  4. 

Macdonald^s  Surgical  Diagnosis,  just  Ready.  Sec  page  J6. 

Anders^  Practice  of  Medicine — Revised  Edition.   See  page  6. 

Moore^s  Orthopedic  Surgery,  just  Ready.   See  page  I7. 

Penrose^s  Diseases  of  Women.   See  page  J8. 

Mallory  and  Wright^s  Pathological  Technique.   See  page  I6. 

Van  Valzah  and  Nisbet^s  Diseases  of  the  Stomach.   See  page  28. 

American  Year-Book  of  Medicine  and  Surgery.  See  page  6. 

Sennas  Genito-Urinary  Tuberculosis.  Sec  page  25. 

Sutton  and  Giles^  Diseases  of  Women.  See  page  28. 

Stoney^s  Nursing — Revised  Edition.   See  page  27. 

Garrigues^  Diseases  of  Women — Revised  Edition.  See  page  Ji. 

Keen^s  Surgical  Complications  of  Typhoid  Fever.  See  page  J5. 

Gould  and  Pyle^s  Curiosities  of  Medicine.  See  page  n. 

De  Schweinitz*  Diseases  of  the  Eye — Revised  Edition.  Page  lo. 

Chapin's  Compendium  of  Insanity.  Just  Ready.   See  page  8. 

Church  and  Peterson^s  Nervous  and  Mental  Diseases.   Page  9. 

Saunders^  Medical  Hand-Atlases.   See  page  2. 

DaCosta^s  Surgery — Revised  and  Enlarged  Edition.    See  page  lo. 


SPECIAL  ANNOUNCEMENT. 


Mr.  Saunders  is  pleased  to  announce  that  arrangements  have  been  completed  for  the 
publication  of  an  English  edition  of  the  world-famous 

Lehmann  medicinische  Handatlanten. 

For  scientific  accuracy,  pictorial  beauty,  compactness,  and  cheapness  these  books 
surpass  any  similar  volumes  ever  published.     Each  volume  contains  from 

50  to  100  Colored  Plates, 

besides  numerous  other  illustrations  in  the  text.  These  colored  plates  have  been  executed 
by  the  most  skilful  German  lithographers,  in  some  cases  twenty  or  more  impressions  being 
required  to  obtain  the  desired  result.  There  is  a  full  and  appropriate  description  of  each 
plate  (printed,  for  convenience,  opposite  the  plate) ,  together  with  a  condensed  outline  of 
the  subject  to  which  the  book  is  devoted. 

The  same  careful  and  competent  editorial  supervision  will  be  secured  in  the 
English  edition  as  in  the  originals.  The  translations  will  be  directed  and  edited  by  the 
leading  American  specialists  in  the  different  subjects. 

The  great  advantage  of  natural  pictorial  representation  is  indisputable.  For  lasting  and 
practical  knowledge,  one  accurate  illustration  is  better  than  several  pages  of  dry 
description. 

These  Atlases  offer  a  ready  and  satisfactory  substitute  for  clinical  observation,  avail- 
able only  to  the  residents  of  large  medical  centers ;  and  with  such  persons  the  requisite 
variety  is  seen  only  after  long  years  of  routine  hospital  service. 

By  reason  of  their  projected  universal  translation  and  reproduction,  affording  inter- 
national distribution,  the  publishers  have  been  enabled  to  secure  for  these  Atlases  the  best 
artistic  and  professional  talent,  to  produce  them  in  the  most  elegant  style,  and  yet  to 
offer  them  at  a  price  heretofore  unapproached  in  cheapness.  The  success  of  the  under- 
taking is  demonstrated  by  the  fact  that  volumes  have  already  appeared  in  German,  English, 
French,  Italian,  Russian,  Spanish,  Danish,  Swedish,  and  Hungarian. 

While  appreciating  the  value  of  such  colored  plates,  the  profession  has  heretofore  been 
practically  debarred  from  purchasing  similar  works  because  of  their  extremely  high  price, 
made  necessary  by  the  limited  sale  and  the  enormous  expense  of  production.  The  very 
low  price  of  these  Atlases  will  place  them  within  the  reach  of  even  the  novice  in  practice. 

NOW  READY. 

Atlas  of  Internal  Medicine  and  Clinical  Diagnosis.  By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited 
b5' Augustus  A.  Eshner,  M.D.,  Professor  of  Clinical  Medicine  in  the  Philadelphia  Polyclinic;  At- 
tending Physician  to  the  Philadelphia  Hospital.  68  colored  plates,  and  64  illustrations'in  the  text. 
Cloth,  $3.00  net.  ' 

Atlas  of  Legal  Medicine.  By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited  by  Frederick  Peter- 
son, M.D.,  Clinical  Professor  of  Mental  Diseases,  Woman's  Medical  College,  New  York;  Chief 
of  Clinic,  Nervous  Dept.,  College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  fig- 
ures on  56  plates,  and  193  beautiful  half-tone  illustrations.     Cloth,  fo.50  net. 

Atlas  of  Diseases  of  the  Larynx.  By  Dr.  L.  Grunwald,  of  Munich.  Edited  by  Charles  P. 
Grayson,  M.D.,  Lecturer  on  Laryngology  and  Rhinology  in  the  University  of  Pennsylvania; 
Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania. 
With  107  colored  figures  on  44  plates,  and  25  text-illustrations.     Cloth,  $2.50  net. 

Atlas  of  Operative  Surgery.  By  Dr.  O.  Zuckkrkandl,  of  Vienna.  Edited  by  J.  Chalmers 
DaCosta,  M.D.,  Clinical  Professor  of  Surgery,  Jeft'erson  Medical  College,  Philadelphia;  Surgeon 
to  the  Philadelphia  Hospital.     With  24  colored  plates,  and  217  text  illustrations.     Cloth,  |3.oojiet. 

Atlas  of  Syphilis  and  the  Venereal  Diseases.  By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited 
by  L.  Bolton  Bangs,  M.D.,  late  Professor  of  Genito-Urinary  and  Venereal  Diseases,  New  York 
Post-Graduate  Medical  School  and  Hospital.  With  71  colored  plates  from  original  water-colors, 
and  16  black-and-white  illustrations.     Cloth,  I3.50  net. 

IN  PREPARATION. 

Atlas  of  External  Diseases  of  the  Eye.  By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E. 
de  Schweinitz,  M.D.,  Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia. 
With  100  colored  illustrations. 

Atlas  of  Skin  Diseases.  By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  With  80  colored  plates  from 
original  water-colors. 

Atlas  of  Pathological  Histology.  Atlas  of  Operative  Gynecology. 

Atlas  of  Orthopedic  Surgery.  Atlas  of  Psychiatry. 

Atlas  of  Qenerai  Surgery.  Atlas  of  Diseases  of  the  Ear. 


THE  AMERICAN   TEXT-BOOK  SERIES. 

AN  AMERICAN  TEXT=BOOK  OF  APPLIED  THERAPEUTICS. 

By  43  Distinguished  Practitioners  and  Teachers.  Edited  by  James  C. 
Wilson,  M.D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical 
Medicine  in  the  Jefferson  Medical  College,  Philadelphia.  One  hand- 
some imperial  octavo  volume  of  1326  pages.  Illustrated.  Cloth, 
$7.00  net;  Sheep  or  Half  Morocco,  ^8.00  net.     So/d  by  Subscription. 

"  As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  of 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician." — Chicago  Clinical  Review. 

"The  whole  field  of  medicine  has  been  well  covered.  The  work  is  thoroughly  prac- 
tical, and  while  it  is  intended  for  practitioners  and  students,  it  is  a  better  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful." — The  Indian  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  DISEASES  OF  CHILDREN. 

By  di  Eminent  Contributors.  Edited  by  Louis  Starr,  M.D.  ,  Physi- 
cian to  the  Children's  Hospital,  Philadelphia,  etc.;  assisted  by 
Thompson  S.  Westcott,  M.D.,  Attending  Physician  to  the  Dispen- 
sary for  Diseases  of  Children,  Hospital  of  the  University  of  Pennsyl- 
vania. In  one  handsome  imperial  octavo  volume  of  11 90  pages, 
profusely  illustrated.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
|8.oo  net.     Sold  by  Subscription. 

"  This  is  far  and  away  the  best  text-book  on  children's  diseases  ever  published  in  the 
English  language,  and  is  certainly  the  one  which  is  best  adapted  to  American  readers. 
We  congratulate  the  editor  upon  the  result  of  his  work,  and  heartily  commend  it  to  the 
attention  of  every  student  and  practitioner. " — American  Journal  of  the  Medical  Sciences. 

AN  AMERICAN  TEXT=BOOK  OF  DISEASES  OF  THE  EYE,  EAR, 
NOSE,  AND  THROAT. 

By  58  Prominent  Specialists.  Edited  by  G.  E.  de  Schweinitz,  M.D. , 
Professor  of  Ophthalmology  in  the  Jefferson  Medical  College,  Phila- 
delphia ;  and  B.  Alexander  Randall,  M.D.,  Professor  of  Diseases 
of  the  Ear  in  the  University  of  Pennsylvania  and  in  the  Philadelphia 
Polyclinic.     Heady  soon. 


Illustrated  Catalogue  of  the  ** American  Text-Books"  sent  free  upon  application. 


4  Medical  Publications  of  W.  B.  Saunders. 

AN  AMERICAN   TEXT=BOOK    OF   QENITO=URINARY  AND  SKIN 
DISEASES. 

By  47  Eminent  Specialists  and  Teachers.  Edited  by  L.  Bolton 
Bangs,  M.D.  ,  Late  Professor  of  Genito-Urinary  and  Venereal  Diseases, 
New  York  Post-Graduate  Medical  School  and  Hospital ;  and  W. 
A.  Hardaway,  M.D.,  Professor  of  Diseases  of  the  Skin,  Missouri 
Medical  College.     Cloth,  ^7.00  net;  Sheep  or  Half  Morocco,  ^8.00  net. 

This  latest  addition  to  the  series  of  "  American  Text-Books  "  it  is  confidently  believed  will  meet 
the  requirements  of  both  students  and  practitioners,  giving,  as  it  does,  a  comprehensive  and  detailed 
presentation  of  the  Diseases  of  the  Genito-Urinary  Organs,  of  the  Venereal  Diseases,  and  of  the 
Affections  of  the  Skin. 

Having  secured  the  collaboration  of  well-known  authorities  in  the  branches  represented  in  the 
Mndertaking,  the  Editors  have  not  restricted  the  Contributors  in  regard  to  the  particular  views  set 
forth,  but  have  offered  every  facility  for  the  free  expression  of  their  individual  opinions.  The  work 
will  therefore  be  found  to  be  original,  yet  homogeneous  and  fully  representative  of  the  several  depart- 
ments of  medical  science  with  which  it  is  concerned. 

AN  AMERICAN  TEXT=BOOK  OF  GYNECOLOGY,  MEDICAL  AND 
SURGICAL. 

By  10  of  the  Leading  Gynecologists  of  America.     Edited  by  J.   M. 
Baldy,  M.D.,  Professor  of  Gynecology  in  the  Philadelphia  Polyclinic, 
etc.     Handsome  imperial  octavo  volume  of  over  70Q  pages,  with  360 
illustrations  in  the  text,  and  37  colored  and  half-tone  plates.     Cloth, 
;g6.oo  net;  Sheep  or  Half  Morocco,  $7.00  net.     Sold dy  Sicbscription. 
"  It  is  practical  from  beginning  to  end.     Its  descriptions  of  conditions,  its  recommen- 
dations for  treatment,  and  above  all  the  necessary  technique  of  different  operations,  are 
clearly  and  admirably  presented.     .     .     .     It  is  well  up  to  the  most  advanced  views  of  the 
day,  and  embodies  all  the  essential  points  of  advanced  American  gynecology.     It  is  destined 
to  make  and  hold  a  place  in  gynecological   literature  which  will  be  peculiarly  its  own." — 
Medical  Record,  New  York. 

AN  AMERICAN  TEXT=BOOK  OF  LEGAL  MEDICINE  AND  TOXI- 
COLOGY. 

Edited  by  Frederick  Peterson,  M.D.,  Clinical  Professor  of  Mental 
Diseases  in  the  Woman's  Medical  College,  New  York;  Chief  of  Clinic, 
Nervous  Department,  College  of  Physicians  and  Surgeons,  New  York  ; 
and  Walter  S.  Haines,  M.D.,  Professor  of  Chemistry,  Pharmacy, 
and  Toxicology  in  Rush  Medical  College,  Chicago.    In  Preparation. 

AN  AMERICAN  TEXT=BOOK  OF  OBSTETRICS. 

By  15  Eminent  American  Obstetricians.  Edited  by  Richard  C.  Nor- 
Ris,  M.D.;  Art  Editor,  Robert  L.  Dickinson,  M.D.  One  handsome 
imperial  octavo  volume  of  over  1000  pages,  with  nearly  900  beautiful 
colored  and  half-tone  illustrations.  Cloth,  $7.00  net;  Sheep  or  Half 
Morocco,  ^8.00  net.     Sold  by  Subscription. 

"  Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers. " — Alexander 
J.  C.  Skene,  Professor  of  Gynecology  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  V. 

"  This  is  the  most  sumptuously  illustrated  work  on  midwifery  that  has  yet  appeared.  In 
the  number,  the  excellence,  and  the  beauty  of  production  of  the  illustrations  it  far  surpasses- 
every  other  book  upon  the  subject.  This  feature  alone  makes  it  a  work  which  no  medical 
library  should  omit  to  purchase." — British  Medical  Journal. 

"As  an  authority,  as  a  book  of  reference,  as  a  '  working  book '  for  the  student  or  prac- 
titioner, we  commend  it  because  we  believe  there  is  no  better." — American  Journal  of  the- 
Medical  Sciences. 

IlltJstf ated  Catalogue  of  the  ** American  Text-Books  '*  sent  free  upon  application. 


Medical  Publications  of  W.  B.  Saunders.  5 

AN  AMERICAN  TEXT=BOOK  OF  PATHOLOGY. 

Edited  by  John  Guiteras,  M.D.,  Professor  of  General  Pathology  and 
of  Morbid  Anatomy  in  the  University  of  Pennsylvania;  and  David 
RiESMAN,  M.D. ,  Demonstrator  of  Pathological  Histology  in  the 
University  of  Pennsylvania.     In  Prepa7-atiofi. 

AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY. 

By  lo  of  the  Leading  Physiologists  of  America.  Edited  by  William 
H.  Howell,  Ph.D.,  M.D.,  Professor  of  Physiology  in  the  Johns  Hop- 
kins University,  Baltimore,  Md.  One  handsome  imperial  octavo 
volume  of  1052  pages.  Illustrated.  Cloth,  $6.00  net ;  Sheep  or  Half 
Morocco,  ^7.00  net.     Sold  by  Subscription. 

"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  subjects." — London  Lancet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  status  of  the  science  of  physiology  in  the 
English  language." — Amen'can  Journal  of  the  Aledical  Sciences. 

AN  AMERICAN  TEXT-BOOK  OF  SURGERY.     Second  Edition. 

By  13  Eminent  Professors  of  Surgery.     Edited  by  William  W.  Keen, 
M,D.,  LL.D.,   and  J.   William   White,  M.D.,   Ph.D.      Handsome 
imperial  octavo  volume  of  1250  pages,  with  500  wood-cuts  in  the  text, 
and  39  colored  and  half-tone  plates.     Thoroughly  revised  and  enlarged, 
with  a  section  devoted  to  "  The  Use  of  the  Rontgen  Rays  in  Surgery." 
Cloth,  ^7.00  net;  Sheep  or  Half  Morocco,  $8.00  net.     Sold  by  Sub- 
scription. 
"  Personally,  I  should  not  mind  it  being  called  THE  Text-Book  (instead  of  A  Text- 
Book),  for  I  know  of  no  single  volume  which  contains  so  readable  and  complete  an  account 
of  the  science  and  art  of  Surgery  as  this  does." — Edmund  Owen,  F.R.C.S.,  Member  of 
the  Board  of  Examiners  of  the  Royal  College  of  Surgeotts,  England. 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
London  Lancet. 

AN  AMERICAN  TEXT-BOOK  OF  THE  THEORY  AND  PRACTICE 
OF  MEDICINE. 

By  12  Distinguished  American  Practitioners.  Edited  by  William 
Pepper,  M.D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medi- 
cine and  of  Clinical  Medicine  in  the  University  of  Pennsylvania.  Two 
handsome  imperial  octavo  volumes  of  about  1000  pages  each.  Illus- 
trated. Prices  per  volume  :  Cloth,  $5.00  net ;  Sheep  or  Half  Morocco, 
$6.00  net.     Sold  by  Subscription. 

"  I  am  quite  sure  it  will  commend  itself  both  to  practitioners  and  students  of  medicine, 
and  become  one  of  our  most  popular  text-books." — Alfred  Loomis,  M.D.,  LL.D.,  Pro- 
fessor of  Pathology  and  Practice  of  Medicine,  University  of  the  City  of  New  York. 

"  We  reviewed  the  first  volume  of  this  work,  and  said  :  '  It  is  undoubtedly  one  of  the 
best  text-books  on  the  practice  of  medicine  which  we  possess. '  A  consideration  of  the 
second  and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work 
is  in  our  opinion  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see. " — New  York  Medical 
Jonrnal. 

Illustrated  Catalogue  of  the  **  American  Text-Books"  sent  free  upon  application. 


6  Medical  Publications  of  W.  B.  Saunders. 

AN  AMERICAN  YEAR=BOOK  OF  MEDICINE  AND  SURGERY. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and 
investigators.  Collected  and  arranged,  with  critical  editorial  com- 
ments, by  eminent  American  specialists  and  teachers,  under  the  general 
editorial  charge  of  George  M.  Gould,  M.D.  One  handsome  imperial 
octavo  volume  of  about  1200  pages.  Uniform  in  style,  size,  and 
general  make-up  with  the  "American  Text-Book"  Series.  Cloth, 
^6.50  net;  Half  Morocco,  ^7.50  net.     Sold  by  Subscription. 

"  It  is  difficult  to  know  which  to  admire  most — the  research  and  industry  of  the  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enhsted  in  the  service  of  the  Year-Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  .  .  .  It  is  much  more  than  a  mere  compilation  of  abstracts, 
for,  as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the 
advantage  of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers 
fully  qualified  to  perform  these  tasks.  .  .  .  It  is  emphatically  a  book  which  should  find 
a  place  in  every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous 
'  Jahrbiicher '  of  Germany." — Londott  Lancet. 

ANDERS'  PRACTICE  OF  MEDICINE.    Second  Edition. 

A  Text=Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico- Chirurgical  College,  Philadelphia.  In  one 
handsome  octavo  volume  of  1287  pages,  fully  illustrated.  Cloth, 
$5.50  net;  Sheep  or  Half  Morocco,  ^6.50  net. 

"  It  is  an  excellent  book, — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you  ;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 
James  C.  Wilson,  Professor  of  tJie  Practice  of  Medicine  and  Clinical  Medicine,  Jefferson 
Medical  College,  Philadelphia. 

"  I  consider  Dr.  Anders'  book  not  only  the  best  late  work  on  Medical  Practice,  but  by 
far  the  best  that  has  ever  been  published.  It  is  concise,  systematic,  thorough,  and  fully  up 
to  date  in  everything.  I  consider  it  a  great  credit  to  both  the  author  and  the  publisher." — 
A.  C.  COWPERTHWAITE,  President  of  the  Illijtois  Homeopathic  Medical  Association. 

ASHTON'S  obstetrics.     Fourth  Edition,  Revised. 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D.,  Pro- 
fessor of  Gynecology  in  the  Medico-Chirurgical  College,  Philadelphia. 
Crown  octavo,  252  pages;  75  illustrations.  Cloth,  $1.00;  interleaved 
for  notes,  ^1.25. 

[See  Saunders^  Question- Compends,  page  21.] 

«'  Embodies  the  whole  subject  in  a  nut-shell.  We  cordially  recommend  it  to  our  read- 
ers."—  Chicago  Medical  Tivies. 

BALL'S  BACTERIOLOGY.     Third  Edition,  Revised. 

Essentials  of  Bacteriology  ;  a  Concise  and  Systematic  Introduction 
to  the  Study  of  Micro-organisms.  By  M.  V.  Ball,  M.D.,  Bacteriol- 
ogist to  St.  Agnes'  Hospital,  Philadelphia,  etc.  Crown  octavo,  218 
pages;  82  illustrations,  some  in  colors,  and  5  plates.  Cloth,  ^i.oo; 
interleaved  for  notes,  ^1.25. 

[See  Saunders''  Question- Compends,  page  21.] 

"  The  student  or  practitioner  can  readily  obtain  a  knowledge  of  the  subject  from  a  perusal 
of  this  book.     The  illustrations  are  clear  and  satisfactory." — Medical  Record,  New  York. 


Medical  Publications  of  W.  B.  Saunders.  7 

BASTIN'S  BOTANY. 

Laboratory  Exercises  in  Botany.  By  Edson  S.  Bastin,  M.A., 
late  Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.    Octavo  volume  of  536  pages,  with  87  plates.    Cloth,  $2.50. 

"It  is  unquestionably  the  best  text-book  on  the  subject  that  has  yet  appeared.  The 
work  is  eminently  a  practical  one.  We  regard  the  issuance  of  this  l)ook  as  an  important 
event  in  the  history  of  pharmaceutical  te.iching  in  this  country,  and  predict  for  it  an  unquali- 
fied success." — Aliontii  Report  to  the  Philadelphia  College  of  Pharmacy. 

"There  is  no  work  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  country, 
and  we  predict  for  it  a  wide  circulation." — American  Journal  of  Pharmacy. 

BECK'S  SURGICAL  ASEPSIS. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.D.,  Surgeon  to 
St.  Mark's  Hospital  and  the  New  York  German  Poliklinik,  etc.  306 
pages;  65  text-illustrations,  and  12  full-page  plates.     Cloth,  $1.25  net. 

"An  excellent  exposition  of  the  'very  latest'  in  the  treatment  of  wounds  as  practised 
by  leading  German  and  American  surgeons." — Birmingham  (Eng. )  Medical  Keviexv. 

"This  little  volume  can  be  recommended  to  any  who  are  desirous  of  learning  the  details 
of  asepsis  in  surgery,  for  it  will  serve  as  a  trustworthy  guide." — London  Lancet. 

BOISLINIERE'S  OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND 
OPERATIONS. 
Obstetric  Accidents,  Emergencies,  and  Operations.     By  L.  Ch. 

Boisliniere,  M.D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis 
Medical  College.     381  pages,  handsomely  illustrated.     Cloth,  ^2.00  net. 

"  It  is  clearly  and  concisely  written,  and  is  evidently  the  work  of  a  teacher  and  practi- 
tioner of  large  experience." — British  Medical  Journal. 

"  A  manual  so  useful  to  the  student  or  the  general  practitioner  has  not  been  brought  to 
our  notice  in  a  long  time.  The  field  embraced  in  the  title  is  covered  in  a  terse,  interesting 
way." —  Yale  Medical  Journal. 

BROCKWAY'S  MEDICAL  PHYSICS.     Second  Edition,  Revised. 
Essentials  of   Medical   Physics.     By  Fred  J.  Brockway,  M.D., 
Assistant  Demonstrator  of  Anatomy  in  the  College  of  Physicians  and 
Surgeons,  New  York.     Crown  octavo,  330  pages  ;   155  fine  illustrations. 
Cloth,  $1.00  net ;   interleaved  for  notes,  ^1.25  net. 

[See  Saimders'  Question- Compe?ids,  page  21.] 

"  The  student  who  is  well  versed  in  these  pages  will  certainly  prove  qualified  to  com- 
prehend with  ease  and  pleasure  the  great  majority  of  questions  involving  physical  principles 
likely  to  be  met  with  in  his  medical  studies." — American  Practitioner  and  News. 

"We  know  of  no  manual  that  affords  the  medical  student  a  better  or  more  concise 
exposition  of  physics,  and  the  book  may  be  commended  as  a  most  satisfactory  presentation 
of  those  essentials  that  are  requisite  in  a  course  in  medicine." — New  York  Medical  Journal. 

"  It  contains  all  that  one  need  know  on  the  subject,  is  well  written,  and  is  copiously 
illustrated." — Medical  Record,  New  York. 

BURR  ON  NERVOUS  DISEASES. 

A  Manual  of  Nervous  Diseases.  By  Charles  W.  Burr,  M.D., 
Clinical  Professor  of  Nervous  Diseases,  Medico-Chirurgical  College, 
Philadelphia ;  Pathologist  to  the  Orthopedic  Hospital  and  Infirmary 
for  Nervous  Diseases  j  Visiting  Physician  to  St.  Joseph's  Hospital,  etc. 
I71  Preparation. 


8  Medical  Publications  of  W.  B.  Saunders. 

BUTLER'S   MATERIA    MEDICA,   THERAPEUTICS,   AND   PHAR= 
MACOLOGY. 

A  Text=Book  of  Materia  Medica,  Therapeutics,  and  Pharma^ 
cology.  By  George  F.  Butler,  Ph.G.,  M.D.,  Professor  of  Materia 
Medica  and  of  Clinical  Medicine  in  the  College  of  Physicians  and 
Surgeons,  Chicago ;  Professor  of  Materia  Medica  and  Therapeutics, 
Northwestern  University,  Woman's  Medical  School,  etc.  Octavo,  858 
pages,  illustrated.     Cloth,  ;g4.oo  net;    Sheep,  ^5.00  net. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory 
of  any  single-volume  works  on  materia  medica  in  the  market," — Jottmal  of  the  American 
Medical  Association. 

"The  work  is  executed  in  a  clear,  concise,  and  practical  manner,  and  should  meet  with 
a  hearty  endorsement  from  the  students  of  our  up-to-date  colleges.  The  book  will  be  found 
a  valuable  work  of  reference  for  the  practitioner." — Ai7ierica7i  Aledico-Stirgical Bidletiti. 

CASSELBERRY  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  W.  E.  Casselberry,  Pro- 
fessor of  Laryngology  and  Rhinology  in  the  Northwestern  University 
Medical  School,  Chicago.     Jti  Preparatioji. 

CERNA  ON  THE  NEWER  REMEDIES.  Second  Edition,  Revised. 
Notes  on  the  Newer  Remedies,  their  Therapeutic  Applications 
and  Modes  of  Administration.  By  David  Cerna,  M.D.,  Ph.D., 
formerly  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics 
in  the  University  of  Pennsylvania ;  Demonstrator  of  Physiology  in  the 
Medical  Department  of  the  University  of  Texas.  Rewritten  and 
greatly  enlarged.     Post-octavo,   253  pages.     Cloth,  ^1.25. 

"These  '  Notes  '  will  be  found  very  useful  to  practitioners  who  takg  an  interest  in  the 
many  newer  remedies  of  the  present  day." — Ediiiburgh  Medical  Journal. 

"  The  appearance  of  this  new  edition  of  Dr.  Cerna's  very  valuable  work  shows  that  it 
is  properly  appreciated.  The  book  ought  to  be  in  the  possession  of  every  practising  physi- 
cian."— New  York  Medical  Journal. 

CHAPIN  ON  INSANITY. 

A  Compendium  of  Insanity.     By  John  B.  Chapin,  M.D.,  LL.D., 

Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  late  Physi- 
cian-Superintendent of  the  Willard  State  Hospital,  New  York ;  Hon- 
orary Member  of  the  Medico-Psychological  Society  of  Great  Britain, 
of  the  Society  of  Mental  Medicine  of  Belgium,     Cloth,  ^1.25  net. 

The  author  has  given,  in  a  condensed  and  concise  form,  a  compendium  of  Diseases  of 
the  Mind,  for  the  convenient  use  and  aid  of  physicians  and  students.  The  work  will  also 
prove  valuable  to  members  of  the  legal  profession  and  to  those  who,  in  their  relations  to  the 
insane  and  to  those  supposed  to  be  insane,  often  desire  to  acquire  some  practical  knowledge 
of  insanity  presented  in  a  form  that  may  be  understood  by  the  non-professional  reader. 

CHAPMAN'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 
Second  Edition,  Revised. 
Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence 
in  the  Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55 
illustrations  and  3  full-page  plates  in  colors.     Cloth,  ^1.50  net. 

"The  best  book  of  its  class  for  the  undergraduate  that  we  know  of." — New  York 
Medical  Times. 


Medical  Publications  of  W.  B.  Saunders.  9 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DISEASES. 
Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.D., 
Professor  of  Mental  Diseases  and  Medical  Jurisprudence  in  the  North- 
western University  Medical  School,  Chicago  ;  and  Frederick  Peter- 
son, M.D.,  Clinical  Professor  of  Mental  Dis'=^ases  in  the  Woman's 
Medical  College,  New  York ;  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York.     /;/  Preparatioti. 

CLARKSON'S  HISTOLOGY. 

A   Text=Book    of    Histology,    Descriptive   and    Practical.      By 

Arthur  Clarkson,  M.B.,  CM.  Edin.,  formerly  Demonstrator  of 
Physiology  in  the  Owen's  College,  Manchester;  late  Demonstrator  of 
Physiology  in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages; 
22  engravings  in  the  text,  and  174  beautifully  colored  original  illustra- 
tions.     Cloth,  strongly  bound,  $6.00  net. 

"  The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text- books, 
and  is  to  be  highly  recommended." — A^eiu  York  Medical  Journal. 

"  This  is  one  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the 
book  will  attain  a  well-deserved  popularity  among  our  students." — Chicago  ^Medical  Recorder. 

"The  volume  is  a  most  valuable  addition  to  the  armamentarium  of  the  teacher." — 
Brooklyn  Medical  Journal. 

CLIMATOLOGY. 

Transactions  of  the  Eighth  Annual  Meeting  of  the  American 
Climatological  Association,  held  in  Washington,  September  22-25, 
1 89 1.  Forming  a  handsome  octavo  volume  of  276  pages,  uniform  with 
remainder  of  series.      (A  limited  quantity  only.)     Cloth,  $1.50. 

COHEN  AND  ESHNER'S  DIAGNOSIS. 

Essentials  of  Diagnosis.  By  Solomon  Solis-Cohen,  M.D.,  Pro- 
fessor of  Clinical  Medicine  and  Applied  Therapeutics  in  the  Philadel- 
phia Polyclinic  ;  and  Augustus  A.  Eshner,  M.D.,  Professor  of  Clinical 
Medicine  in  the  Philadelphia  Polyclinic.  Post-octavo,  382  pages;  55 
illustrations.     Cloth,  $1.50  net. 

[See  Saunders^  Question- Compends,  page  21.] 

"  We  can  heartily  commend  the  book  to  all  those  who  contemplate  purchasing  a  'com- 
pend.'  It  is  modern  and  complete,  and  will  give  more  satisfaction  than  many  other  works 
which  are  perhaps  too  prolix  as  well  as  behind  the  times." — Medical  Review,  St.  Louis. 

CORWIN'S  PHYSICAL  DIAGNOSIS. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur 
M.  Corwin,  A.M.,  M.D.,  Demonstrator  of  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago  ;  Attending  Physician  to  Central  Free  Dis- 
pensary, Department  of  Rhinology,  Laryngology,  and  Diseases  of  the 
Chest,  Chicago.    200  pages,  illustrated.   Cloth,  flexible  covers,  $1.25  net. 

"  It  is  excellent.  The  student  who  shall  use  it  as  his  guide  to  the  careful  study  of 
physical  exploration  upon  normal  and  abnormal  subjects  can  scarcely  fail  to  acquire  a  good 
working  knowledge  of  the  subject." — Philadelphia  Polyclinic. 

"A  most  excellent  little  work.  It  brightens  the  memor>'  of  the  differential  diagnostic 
signs,  and  it  arranges  orderly  and  in  sequence  the  various  objective  phenomena  to  logical 
solution  of  a  careful  diagnosis. ' ' — Journal  of  N'e)~vous  and  Mental  Diseases. 


10  Medical  Publications  of  W.  B.  Saunders. 

CRAQIN'S  GYNECOLOGY,     Fourth  Edition,  Revised. 

Essentials  of  Gynaecology.  By  Edwin  B.  Cragin,  M.D.,  Attend- 
ing Gynaecologist,  Roosevelt  Hospital,  Out-Patients'  Department,  New 
York,  etc.  Crown  octavo,  200  pages;  62  fine  illustrations.  Cloth, 
^i.oo;  interleaved  for  notes,  $1.25. 

[See  Saunders^  Question- Co7nJ>ends,  page  21.] 

"  A  handy  volume,  and  a  distinct  improvement  on  students'  compends  in  general.  No 
author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the  student's  needs 
so  thoroughly  as  Dr.  Cragin  has  done." — Medical  Record,  New  York. 

CROOKSHANK'S  BACTERIOLOGY. 

A  Text=Book  of  Bacteriology.  By  Edgar  M.  Crookshank,  M.B,, 
Professor  of  Comparative  Pathology  and  Bacteriology,  King's  College, 
London.  Octavo  volume  of  700  pages,  with  273  engravings  and  22 
original  colored  plates.      Cloth,  ^6.50  net;  Half  Morocco,  ^7.50  net. 

"  To  the  student  who  wishes  to  obtain  a  good  resume  of  what  has  been  done  in  bacteri- 
ology, or  who  wishes  an  accurate  account  of  the  various  methods  of  research,  the  book  may 
be  recommended  with  confidence  that  he  will  find  there  what  he  requires." — London  Lancets 

Da  COSTA'S  SURGERY.  Second  Ed.,  Revised  and  Greatly  Enlarged. 
Modern  Surgery,  General  and  Operative.  By  John  Chalmers 
DaCosta,  M.D.,  Clinical  Professor  of  Surgery,  Jefferson  Medical 
College,  Philadelphia ;  Surgeon  to  the  Philadelphia  Hospital,  etc. 
Handsome  octavo  volume  of  900  pages,  profusely  illustrated.  Cloth, 
^4.00  net;  Half  Morocco,  ^5.00  net. 

"We  know  of  no  small  work  on  surgery  in  the  English  language  which  so  well  fulfils 
the  requirements  of  the  modern  student." — Medico-Chirurgical  Jourtial,  Bristol,  England. 

DE  SCHWEINITZ  ON  DISEASES  OF  THE  EYE.     Second  Edition, 
Revised. 
Diseases  of   the  Eye.     A  Handbook   of   Ophthalmic   Practice. 

By  G.  E.  DE  ScHWEiNiTZ,  M.D.,  Professor  of  Ophthalmology  in  the 
Jefferson  Medical  College,  Philadelphia,  etc.  Handsome  royal  octavo 
volume  of  679  pages,  with  256  fine  illustrations  and  2  chromo-litho- 
graphic  plates.     Cloth,  ^4.00  net ;  Sheep  or  Half  Morocco,  ^5.00  net. 

"  A  clearly  writtenj  comprehensive  manual.  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering 
upon  the  study  of  this  special  branch  of  medical  science." — British  Medical  Journal. 

"  A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.  I  am  satisfied  that  unusual  success  awaits  it." — William 
Pepper,  M.D.,  Professor  of  the  Theory  and  Practice  of  Medicine  and  Clinical  Medicine, 
University  of  Pennsylvania. 

DORLAND'S  OBSTETRICS. 

A  Manual  of  Obstetrics.  By  W.  A.  Newman  Borland,  M.D., 
Assistant  Demonstrator  of  Obstetrics,  University  of  Pennsylvania; 
Instructor  in  Gynecology  in  the  Philadelphia  Polyclinic.  760  pages; 
163  illustrations  in  the  text,  and  6  full-page  plates.     Cloth,  ^2.50  net. 

"By  far  the  best  book  on  this  subject  that  has  ever  come  to  our  notice." — American 
Medical  Review. 

"  It  has  rarely  been  our  duty  to  review  a  book  which  has  given  us  more  pleasure  in  its 
perusal  and  more  satisfaction  in  its  criticism.  It  is  a  veritable  encyclopedia  of  knowledge, 
a  gold  mine  of  practical,  concise  thoughts." — American  Medico-Surgical  Bulletin. 


Medical  Publications  of  W.  B.  Saunders.  11 

FROTHINGHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Froth- 
INGHAM,  M.D.V.,  Assistant  in  Bacteriology  and  Veterinary  Science, 
Sheffield  Scientific  School,  Yale  University.    Illustrated.    Cloth,  75  cts. 

"It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  neces- 
sary for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking 
up  the  various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — Ameri- 
can Aledico- Surgical  Bulletin. 

GARRIGUES'  DISEASES  OF  WOMEN.  Second  Edition,  Revised. 
Diseases  of  Women.  By  Henry  J.  Garrigues,  A.M.,  M.D.,  Pro- 
fessor of  Gynecology  in  the  New  York  School  of  Clinical  Medicine; 
Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dispensary, 
New  York  City,  etc.  Handsome  octavo  volume  of  728  pages,  illus- 
trated by  335  engravings  and  colored  plates.  Cloth,  $4.00  net; 
Sheep  or  Half  Morocco,  $5.00  net. 

"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners  to  whom  experienced  consultants 
may  not  be  available  will  find  in  this  book  invaluable  counsel  and  help." — Thad.  A. 
Reamy,  M.D.,  LL.D.,  Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio. 

GLEASON'S  DISEASES  OF  THE  EAR.  Second  Edition,  Revised. 
Essentials  of  Diseases  of  the  Ear.  By  E.  B.  Gleason,  S.B., 
M.D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Philadelphia  ;  Surgeon-in-Charge  of  the  Nose,  Throat,  and  Ear  Depart- 
ment of  the  Northern  Dispensary,  Philadelphia.  208  pages,  with 
114  illustrations.  Cloth,  $1.00  ;  interleaved  for  notes,  $1.25. 
[See  Saunders'  Question- Compends,  page  21.] 

"  It  is  just  the  book  to  put  into  the  hands  of  a  student,  and  cannot  fail  to  give  him  a 
useful  introduction  to  ear-affections  ;  while  the  style  of  question  and  answer  which  is  adopted 
throughout  the  book  is,  we  believe,  the  best  method  of  impressing  facts  permanently  on  the 
mind. " — Liverpool  Medico-  Chirurgical  Journal. 

GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould, 
M.D.,  and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
exhaustive  research  of  medical  literature  from  its  origin  to  the  present 
day,  abstracted,  classified,  annotated,  and  indexed.  Handsome  im- 
perial octavo  volume  of  968  pages,  with  295  engravings  in  the  text, 
and  12  full-page  plates.  Cloth,  $6.00  net;  Half  Morocco,  $7.00  net. 
Sold  by  Subscnptio/i. 

"  One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far 
as  we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for 
the  medical  profession  has  this  volume  value :  it  will  serve  as  a  book  of  reference  for  all  who 
are  interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyti  Medical 
Journal. 

"This  is  certainly  a  most  remarkable  and  interesting  volume.  It  stands  alone  among 
medical  literature,  an  anomaly  on  anomalies,  in  that  there  is  nothing  like  it  elsewhere  in 
medical  literature.  It  is  a  book  full  of  revelations  from  its  first  to  its  last  page,  and  cannot 
but  interest  and  sometimes  almost  homfy  its  readers." — American  Medico- Surgical  Bulletin. 


12  Medical  Publications  of  W.  B.  Saunders. 

GRIFFIN'S  MATERIA  MEDICA  AND  THERAPEUTICS. 

Manual  of  Materia  Medica  and  Therapeutics.  By  Henry  A. 
Griffin,  A.B.,  M.D.,  Assistant  Physician  to  the  Roosevelt  Hospital, 
Out-Patient  Department,  New  York  City.      In  Preparation. 

GRIFFITH  ON  THE  BABY. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.D.,  Clini- 
cal Professor  of  Diseases  of  Children,  University  of  Pennsylvania ; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  392 
pages,  with  67  illustrations  in  the  text,  and  5  plates.      Cloth,  ^1.50. 

"  The  best  book  for  the  use  of  the  young  mother  with  which  we  are  acquainted.  .  .  . 
There  are  very  few  general  practitioners  who  could  not  read  the  book  through  with  advan- 
tage."— Ay-chives  of  Pediatrics. 

"The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a 
master  hand.  It  can  be  read  with  benefit  not  only  by  mothers  but  by  medical  students  and 
by  any  practitioners  who  have  not  had  large  opportunities  for  observing  children." — Ameri- 
can Journal  of  Obstetrics. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D.  , 
Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penn- 
sylvania, etc.      25  charts  in  each  pad.      Per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child' s  weight  during  the  first  two  years 
of  life.  Printed  on  each  chart  is  a  curve  representing  the  average  weight  of  a  healthy  infant, 
so  that  any  deviation  from  the  normal  can  readily  be  detected. 

GROSS,  SAMUEL  D.,  AUTOBIOGRAPHY  OF. 

Autobiography  of  Samuel  D.  Gross,  M.D.,  Emeritus  Professor  of 
Surgery  in  the  Jefferson  Medical  College,  Philadelphia,  with  Remi- 
niscences of  His  Times  and  Contemporaries.  Edited  by  his  Sons, 
Samuel  W.  Gross,  M.D.,  LL.D.,  late  Professor  of  Principles  of  Sur- 
gery and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and 
A.  Haller  Gross,  A.M.,  of  the  Philadelphia  Bar.  Preceded  by  a 
Memoir  of  Dr.  Gross,  by  the  late  Austin  Flint,  M.D.,  LL.D.  In 
two  handsome  volumes,  each  containing  over  400  pages,  demy  octavo, 
extra  cloth,  gilt  tops,  with  fine  Frontispiece  engraved  on  steel.  Price 
per  volume,  ^2.50  net. 

"  Dr.  Gross  was  perhaps  the  most  eminent  exponent  of  medical  science  that  America 
has  yet  produced.  His  Autobiography,  related  as  it  is  with  a  fulness  and  completeness 
seldom  to  be  found  in  such  works,  is  an  interesting  and  valuable  book.  He  comments  on 
many  things,  especially,  of  course,  on  medical  men  and  medical  practice,  in  a  very  interest- 
ing way." — The  Spectator,  London,  England. 

HAMPTON'S  NURSING. 

Nursing :  Its  Principles  and  Practice.  By  Isabel  Adams  Hamp- 
ton, Graduate  of  the  New  York  Training  School  for  Nurses  attached 
to  Bellevue  Hospital ;  Superintendent  of  Nurses,  and  Principal  of  the 
Training  School  for  Nurses,  Johns  Hopkins  Hospital,  Baltimore,  Md. 
i2mo,  484  pages,  profusely  illustrated.      Cloth,  ^2.00  net. 

"  Seldom  have  we  perused  a  book  upon  the  subject  that  has  given  us  so  much  pleasure 
as  the  one  before  us.  We  would  strongly  urge  upon  the  members  of  our  own  profession  the 
need  of  a  book  like  this,  for  it  will  enable  each  of  us  to  become  a  training  school  in  him- 
self ' ' —  Ontario  Medical  Journal. 


Medical  Publications  of  W.  B.  Saunders.  13 

HARE'S  PHYSIOLOGY.     Third  Edition,  Revised. 

Essentials  of  Physiology.  By  H.  A.  Harr,  M.D.,  Professor  of 
Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  College  of 
Philadelphia;  Physician  to  the  Jefferson  Medical  College  Hospital. 
Containing  a  series  of  handsome  illustrations  from  the  celebrated 
"Icones  Nervorum  Capitis"  of  Arnold.  Crown  octavo,  239  pages. 
Cloth,  ^i.oo  net;  interleaved  for  notes,  $1.25  net. 

[See  Saunders^  Question- Compends,  page  21.] 

"  The  best  condensation  of  physiological  knowledge  we  have  yet  seen." — Aledical 
Record,  New  York. 

HART'S  DIET  IN  SICKNESS  AND  IN  HEALTH. 

Diet  in  Sickness  and  in  Health.  By  Mrs.  Ernest  Hart,  formerly 
Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School 
of  Medicine  for  Women ;  with  an  Introduction  by  Sir  Henry 
Thompson,  F.R.C.S.,  M.D.,  London.  220  pages  ;  illustrated.  Cloth, 
$1.50. 

"  We  recommend  it  cordially  to  the  attention  of  all  practitioners ;  both  to  them  and  to 
their  patients  it  may  be  of  the  greatest  service." — New  York  Medical  Journal. 

HAYNES'  ANATOMY. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Depart- 
ment of  the  New  York  University,  etc.  680  pages,  illustrated  with  42 
diagrams  in  the  text,  and  134  full-page  half-tone  illustrations  from 
original  photographs  of  the  author's  dissections.      Cloth,  $2.50  net. 

"  This  book  is  the  work  of  a  practical  instructor — one  who  knows  by  experience  the 
requirements  of  the  average  student,  and  is  able  to  meet  these  requirements  in  a  very  satis- 
factory way.     The  book  is  one  that  can  be  commended." — Medical  Record,  New  York. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Pro- 
fessor of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 
In  Preparation. 

HIRST'S  OBSTETRICS. 

A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  /«  Prepa- 
ration. 

HYDE  AND  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES. 
Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde, 
M.D.,  Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Mont- 
gomery, M.D.,  Lecturer  on  Dermatology  and  Genito-Urinary  Diseases 
in  Rush  Medical  College,  Chicago,  111.  618  pages,  profusely  illustrated. 
Cloth,  $2.50  net. 

"  We  can  commend  this  manual  to  the  student  as  a  help  to  him  in  his  study  of  venereal 
•diseases. ' ' — Liverpool  Medico-  Chirurgical  Journal. 

"The  best  student's  manual  which  has  appeared  on  the  subject." — St.  Louis  Medical 
and  Surgical  Journal. 


14  Medical  Publications  of  W.  B.  Saunders. 

JACKSON  AND  QLEASON'S  DISEASES  OF  THE  EYE,  NOSE,  AND 
THROAT.  Second  Edition,  Revised. 
Essentials  of  Refraction  and  Diseases  of  the  Eye.  By  Edward 
Jackson,  A.M.,  M.D.,  Professor  of  Diseases  of  the  Eye  in  the  Phila- 
delphia Polyclinic  and  College  for  Graduates  in  Medicine ;  and — 
Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  Bald- 
win Gleason,  M.D.,  Surgeon-in-Charge  of  the  Nose,  Throat,  and 
Ear  Department  of  the  Northern  Dispensary  of  Philadelphia.  Two 
volumes  in  one.  Crown  octavo,  290  pages;  124  illustrations.  Cloth, 
$1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question-Cojjipends,  page  21.] 

"  Of  great  value  to  the  beginner  in  these  branches.  The  authors  are  both  capable  men, 
and  know  what  a  student  most  needs." — Medical  Record,  New  York. 

KEATINQ'S  DICTIONARY.     Second  Edition,  Revised. 

A  New  Pronouncing  Dictionary  of  Medicine,  with  Phonetic 
Pronunciation,  Accentuation,  Etymology,  etc.  By  John  M. 
Keating,  M.D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila-, 
delphia;  Vice-President  of  the  American  Psediatric  Society;  Editor 
"Cyclopaedia  of  the  Diseases  of  Children,"  etc.;  and  Henry 
Hamilton,  Author  of  "A  New  Translation  of  Virgil's  ^neid  into 
English  Rhyme,"  etc.;  with  the  collaboration  of  J.  Chalmers  Da- 
Costa,  M.D.,  and  Frederick  A.  Packard,  M.D.  With  an  Appendix 
containing  Tables  of  Bacilli,  Micrococci,  Leucomaines,  Ptomaines; 
Drugs  and  Materials  used  in  Antiseptic  Surgery;  Poisons  and  their 
Antidotes;  Weights  and  Measures;  Thermometric  Scales;  New 
Official  and  Unofficial  Drugs,  etc.  One  volume  of  over  800  pages. 
Prices,  with  Denison's  Patent  Ready-Reference  Index:  Cloth,  ^5.00 
net;  Sheep  or  Half  Morocco,  $6.00  net;  Half  Russia,  $6.50  net. 
Without  Patent  Index:  Cloth,  $4.00  net;  Sheep  or  Half  Morocco, 
$5.00  net. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommend- 
ing it  to  my  classes." — Henry  M.  Lyman,  M.D.,  Professor  of  the  Principles  mid  Practice 
of  Medicine,  Rush  Medical  College,  Chicago,  III. 

"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient 
in  size  and  sufficiently  full  for  ordinary  use." — C.  A.  LiNDSLEY,  M.D.,  Professor  of  the 
Theory  and  Practice  of  Medicine,  Medical  Dept.   Yale  University. 

KEATINQ'S  LIFE  INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating, 
M.D.,  Fellow  of  the  College  of  Physicians  of  Philadelphia;  Vice- 
President  of  the  American  Paediatric  Society;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages ;  with  two  large  half-tone  illustrations,  and  a  plate  prepared  by 
Dr.  McClellan  from  special  dissections ;  also,  numerous  other  illustra- 
tions.    Cloth,  ^2.00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination, 
a  subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume 
is  Part  II,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  If  for  these  alone,  the  book  should  be  at  the  right 
hand  of  every  physician  interested  in  this  special  branch  of  medical  science." — The  Medical 
News. 


Medical  Publications  of  W.  B.  Saunders.  15 

KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The    Surgical   Complications  and   Sequels  of   Typhoid    Fever. 

By  Wm.  W.  Keen,  M.D.,  LL.D.,  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia; 
Corresponding  Member  of  the  Societe  de  Chirurgie,  Paris ;  Honorary 
Member  of  the  Societe  Beige  de  Chirurgie,  etc.  Octavo  volume  of 
386  pages,  illustrated.      Cloth,  $3.00  net. 

This  monograph  is  the  only  one  in  any  language  covering  the  entire  subject  of  the 
Surgical  Complications  and  Sequels  of  Typhoid  Feser.  It  will  prove  to  be  of  importance 
and  interest  not  only  to  the  general  surgeon  and  physician,  but  also  to  many  specialists — laryn- 
gologists,  gy^necologists,  pathologists,  and  bacteriologists. 

KEEN'S  OPERATION  BLANK.  Second  Edition,  Revised  Form. 
An  Operation  Blank,  with  Lists  of  Instruments,  etc.  Required 
in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.D.,  LL.D., 
Professor  of  the  Principles  of  Surgery  in  Jefferson  Medical  College, 
Philadelphia.  Price  per  pad,  containing  blanks  for  fifty  operations, 
50  cents  net. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.D., 
Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical 
College,  Philadelphia;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital ;  Bacteriologist  to  the  Philadelphia 
Orthopedic  Hospital.     ///  Freparatmi. 

LAINE'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.D.  Size  8  x  v^y^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature, 
with  columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions, 
Food,  Remarks,  etc.  On  the  back  of  each  chart  is  given  in  full  the 
method  of  Brand  in  the  treatment  of  Typhoid  Fever.  Price,  per  pad 
of  25  charts,  50  cents  net. 

"  To  the  busy  practitioner  this  chart  will  be  found  of  great  value  in  fever  cases,  and 
especially  for  cases  of  typhoid." — Indian  Lancet,  Calcutta. 

LOCKWOOD'S  PRACTICE  OF  MEDICINE. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lock- 
wood,  M.D.,  Professor  of  Practice  in  the  Woman's  Medical  College 
of  the  New  York  Infirmary,  etc.  935  pages,  with  75  illustrations  in 
the  text,  and  22  full-page  plates.      Cloth,  $2.50  net. 

"  Gives  in  a  most  concise  manner  the  points  essential  to  treatment  usually  enumerated 
in  the  most  elaborate  works." — Massachusetts  Medical  Journal. 

LONG'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "  An 
American  Text=Book  of  Gynecology."  By  J.  W.  Long,  M.D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of 
Virginia,  etc.      Cloth,  interleaved,  $1.00  net. 

"  The  book  is  certainly  an  admirable  resume  of  what  every  gynecological  student  and 
practitioner  should  know,  and  will  prove  of  value  not  only  to  those  who  have  the  '  American 
Text-Book  of  Gynecology,'  but  to  others  as  well." — Brooklyn  Medical  Journal. 


16  Medical  Publications  of  W.  B.  Saunders, 

MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.D. 
Edin.,  L.R.  C.S.,  Edin.,  Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery  in  Hamline  University;  Visiting  Surgeon  to  St. 
Barnabas'  Hospital,  Minneapolis,  etc.  Handsome  octavo  volume  of 
800  pages,  profusely  illustrated.  Cloth,  I5.00  net;  Half  Morocco, 
^6.00  net. 

"  A  thorough  and  complete  work  on  surgical  diagnosis  and  treatment,  free  from  pad- 
ding, full  of  valuable  material,  and  in  accord  with  the  surgical  teaching  of  the  day." — The 

Medical  Nezvs,  New  York. 

"The  work  is  brimful  of  just  the  kind  of  practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  book  because  of  its  intrinsic 
value  to  the  medical  practitioner." — Cincinnati  Lancet-Clinic. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work 
in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank 
B.  Mallory,  A.M.,  M.D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.M., 
M.D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.  Octavo  volume  of  396  pages,  handsomely  illustrated.  Cloth, 
^2.50  net. 

"  I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glad  to  say  that 
I  find  it  to  be  a  most  useful  laboratory  and  post-mortem  guide,  full  of  practical  information, 
and  well  up  to  date." — William  H.  Welch,  Professor  of  Pathology,  fohns  Hopkins  Uni- 
versity, Baltimore,  Md. 

MARTIN'S  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 
DISEASES.  Second  Edition,  Revised. 
Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of 
Genito-Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crown 
octavo,  166  pages,  with  78  illustrations.  Cloth,  ^i.oo  ;  interleaved  for 
notes,  ^1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"A  very  practical  and  systematic  study  of  the  subjects,  and  shows  the  author's  famil- 
iarity with  the  needs  of  students."  —  Therapeutic  Gazette. 

MARTIN'S  SURGERY.     Sixth  Edition,  Revised. 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Surgi- 
cal Landmarks,  Minor  and  Operative  Surgery,  and  a  complete  de- 
scription, with  illustrations,  of  the  Handkerchief  and  Roller  Bandages. 
By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of  Genito- 
Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crown  octavo,  338 
pages,  illustrated.  With  an  Appendix  containing  full  directions  for  the 
preparation  of  the  materials  used  in  Antiseptic  Surgery,  etc.  Cloth, 
$1.00;   interleaved  for  notes,  ^1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"  Contains  all  necessary  essentials  of  modern  surgery  in  a  comparatively  small  space. 
Its  style  is  interesting,  and  its  illustrations  are  admirable." — Medical  and  Surgical  Reporter. 


Medical  Publications  of  W.  B.  Saunders.  17 


MCFARLAND'S  PATHOGENIC  BACTERIA. 

Text-Book  upon  the  Pathogenic  Bacteria.  Specially  written 
for  Students  of  Medicine.  By  Joseph  AIcFarland,  M.D.,  Pro- 
fessor of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical  College 
of  Philadelphia,  etc.  Octavo  volume  of  359  pages,  finely  illustrated. 
Cloth,  $2.50  net. 

"  Dr.  McFarland  lias  treated  the  subject  in  a  systematic  manner,  and  has  succeeded  in 
presenting  in  a  concise  and  readable  form  the  essentials  of  bacteriology  up  to  date.  Alto- 
gether, the  book  is  a  satisfactory  one,  and  I  shall  take  pleasure  in  recommending  it  to  the 
students  of  Trinity  College."— H.  B.  Anderson,  M.D.,  Professor  of  Pathology  and  Bac- 
teriologv.  Trinity  Medical  College^  Toronto. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.D.  Bound 
in  limp  cloth,  flush  edges,  25  cents  net. 

"This  pamphlet  is  worth  many  times  over  its  price  to  the  physician.  The  author's 
experiments  and  conclusions  are  original,  and  have  been  the  means  of  doing  much  good." — 
Medical  Bulletin. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D., 
Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery^ 
University  of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo 
volume  of  356  pages,  handsomely  illustrated.      Cloth,  ^2.50  net. 

A  practical  book  based  upon  the  author's  experience,  in  which  special  stress  is  laid 
upon  early  diagnosis,  and  treatment  such  as  can  be  carried  out  by  the  general  practitioner. 
The  teachings  of  the  author  are  in  accordance  with  his  belief  that  true  conservatism  is  to 
be  found  in  the  middle  course  between  the  surgeon  who  operates  too  frequently  and  the 
orthopedist  who  seldom  operates. 

MORRIS'S  MATERIA  MEDICA  AND  THERAPEUTICS.  Fourth 
Edition,  Revised. 
Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription- 
Writing.  By  Henry  Morris,  M.D.,  late  Demonstrator  of  Thera- 
peutics, Jefferson  Medical  College,  Philadelphia;  Fellow  of  the  College 
of  Physicians,  Philadelphia,  etc.  Crown  octavo,  250  pages.  Cloth, 
$1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"  This  work,  already  excellent  in  the  old  edition,  has  been  largely  improved  by  revi- 
sion." — American  Practitioner  and  News. 

MORRIS,  WOLFF,  AND  POWELL'S    PRACTICE   OF   MEDICINE. 
Third  Edition,  Revised. 
Essentials  of  the  Practice  of  Medicine.    By  Henry  Morris,  M.D., 

late  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia ;  with  an  Appendix  on  the  Clinical  and  Microscopic  Examina- 
tion of  Urine,  by  Lawrence  Wolff,  M.  D.  ,  Demonstrator  of  Chemistry, 
Jefferson  Medical  College,  Philadelphia.  Enlarged  by  some  300  essen- 
tial formulae  collected  and  arranged  by  William  M.  Powell,  M.D. 
Post-octavo,  488  pages.     Cloth,  $2.00. 

[See  Saunders'  Question- Compends,  page  21.] 

"  The  teaching  is  sound,  the  presentation  graphic  ;  matter  full  as  can  be  desired,  and 
style  attractive." — American  Practitioner  and  News. 
2 


18  Medical  Publications  of  W.  B.  Saunders. 

MORTEN'S  NURSE'S  DICTIONARY, 

Nurse's  Dictionary  of  Medical  Terms  and  Nursing  Treat= 
ment.  Containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms  and  Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Acci- 
dents, Treatments,  Operations,  Foods,  Appliances,  etc.  encountered 
in  the  ward  or  in  the  sick-room.  By  Honnor  Morten,  author  of 
''How  to  Become  a  Nurse,"  etc.     i6mo,  140  pages.     Cloth,  ^i.oo. 

"  A  handy,  compact  little  volume,  containing  a  large  amount  of  general  information,  all 
of  which  is  arranged  in  dictionary  or  encyclopedic  form,  thus  facilitating  quick  reference. 
It  is  certainly  of  value  to  those  for  whose  use  it  is  published." — Chicago  Clinical  Review. 

NANCREDE'S  ANATOMY.     Fifth  Edition. 

Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera. 
By  Charles  B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clini- 
cal Surgery  in  the  University  of  Michigan,  Ann  Arbor.  Crown  octavo, 
388  pages;  180  illustrations.  With  an  Appendix  containing  over  60 
illustrations  of  the  osteology  of  the  human  body.  Based  upon  Gray' s 
Anatomy.  Cloth,  ^i.oo;  interleaved  for  notes,  ^1.25. 
[See  Saunders'  Question- Compe7ids ,  page  21.] 

"For  self-quizzing  and  keeping  fresh  in  mind  the  knowledge  of  anatomy  gained  at 
school,  it  would  not  be  easy  to  speak  of  it  in  terms  too  favorable." — A^nerican  Practitioner. 

NANCREDE'S  ANATOMY  AND  DISSECTION.     Fourth  Edition. 
Essentials  of  Anatomy  and    Manual  of   Practical    Dissection. 

By  Charles  B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clinical 
Surgery,  University  of  Michigan,  Ann  Arbor.  Post-octavo;  500  pages, 
with  full-page  lithographic  plates  in  colors,  and  nearly  200  illustrations. 
Extra  Cloth  (or  Oilcloth  for  the  dissection-room),  $2.00  net. 

"  It  may  in  many  respects  be  considered  an  epitome  of  Gray's  popular  work  on  general 
anatomy,  at  the  same  time  having  some  distinguishing  characteristics  of  its  own  to  commend 
it.  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students 
in  their  work  in  the  dissecting  room." — Journal  of  the  American  Medical  Association. 

NORRIS'S  SYLLABUS  OF  OBSTETRICS.  Third  Edition,  Revised. 
Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department 
of  the  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.M.,  M.D.,  Demonstrator  of  Obstetrics,  University  of  Pennsylvania. 
Crown  octavo,  222  pages.      Cloth,  interleaved  for  notes,  ^2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in 
calling  attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner." — Medical  Record,  New  York. 

PENROSE'S  DISEASES  OF  WOMEN.     Second  Edition,  Revised. 
A  Text=Book  of  Diseases  of  Women.     By  Charles  B.  Penrose, 
M.D.,  Ph.D.,  Professor  of  Gynecology  in  the  University  of  Pennsyl- 
vania;   Surgeon    to   the   Gynecean    Hospital,    Philadelphia.     Octavo 
volume  of  529  pages,  handsomely  illustrated.     Cloth,  ^3.50  net. 

"I  shall  value  very  highly  the  copy  of  Penrose's  'Diseases  of  Women'  received. 
I  have  already  recommended  it  to  my  class  as  THE  BEST  book."— Howard  A.  Kelly, 
Professor  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Md. 

"  The  book  is  to  be  commended  without  reserve,  not  only  to  the  student  but  to  the 
general  practitioner  wlio  wishes  to  have  the  latest  and  best  modes  of  treatment  explained 
with  absolute  clearness." — Therapeutic  Gazette. 


Medical  Publications  of  W.  B.  Saunders.  19 


POWELL'S  DISEASES  OF  CHILDREN.     Second  Edition. 

Essentials  of  Diseases  of  Children.  By  William  M.  Powell, 
M.D.,  Attending  Thysician  to  the  Mercer  House  for  Invalid  Women 
at  Atlantic  City,  N.  J.  ;  late  Physician  to  the  Clinic  for  the  Diseases  of 
Children  in  the  Hospital  of  the  University  of  Pennsylvania.  Crown 
octavo,  222  pages.  Cloth,  $i.oo;  interleaved  for  notes,  $1.25. 
[See  Saunders'  Question-  Comp ends ,  page  21.] 

"Contains  the  gist  of  all  the  best  works  in  the  department  to  which  it  relates." — 
American  Practitioner  and  Neivs. 

PRINQLE'S  SKIN  DISEASES  AND  SYPHILITIC  AFFECTIONS. 
Pictorial  Atlas  of  Skin  Diseases  and  Syphilitic  Affections 
(American  Edition).  Translation  from  the  French.  Edited  by 
J.  J.  Pringle,  M.B.,  F.R.C.P.,  Assistant  Physician  to  the  Middlesex 
Hospital,  London.  Photo-lithochromes  from  the  famous  models  in 
the  Museum  of  the  Saint-Louis  Hospital,  Paris,  with  explanatory  wood- 
cuts and  text.  In  12  Parts.  Price  per  Part,  $3.00.  Complete  in 
one  volume,  Half  Morocco  binding,  $40.00  net. 

<'  I  strongly  recommend  this  Atlas.  The  plates  are  exceedingly  well  executed,  and 
will  be  of  great  value  to  all  studying  dermatology." — Stephen  Mackenzie,  M.D. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — New  York  Medical  Journal. 

PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Direc- 
tions concerning  the  Immediate  Treatment  of  Cases  of  Emergency. 
For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S.,  late 
Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo,  with  over  80 
illustrations.      Cloth,  flexible  covers,  75  cents  net. 

"  The  directions  are  clear  and  the  illustrations  are  good." — London  Lancet. 
"  The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  port- 
able, although  the  paper  and  type  are  good." — British  Medical  Journal. 

RAYMOND'S  PHYSIOLOGY. 

A  Manual  of  Physiology.  By  Joseph  H.  Raymond,  A.M.,  M.D., 
Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital ;  Director  of  Physiology  in  the 
Hoagland  Laboratory,  etc.  382  pages,  with  102  illustrations  in  the 
text,  and  4  full-page  colored  plates.      Cloth,  ^1.25  net. 

<'  Extremely  well  gotten  up,  and  the  illustrations  have  been  selected  with  care.  The 
text  is  fully  abreast  with  modern  physiology." — British  Medical  Joui-nal. 

RONTGEN  RAYS. 

Archives  of  the  Rontgen  Ray  (Formerly  Archives  of  Clinical 
Skiagraphy).  Edited  by  Sydney  Rowland,  M.A.,  M.R.C.S.,  and 
W.  S.  Hedley,  M.D.,  M.R.C.S.  A  series  of  collotype  illustrations, 
with  descriptive  text,  illustrating  the  applications  of  the  new  photo- 
graphy to  Medicine  and  Surgery.  Price  per  Part,  ^i.oo.  Now  ready: 
Vol.  I.,  Parts  I.  to  IV.;  Vol.  II.,  Parts  I.,  II. 


SaTINDFRS^  ^^^^^^^  ^^  Question  and 

^^  Answer  Form> 

V^  U  Ho  1  IwiN  np^HE  MOST  COMPLETE  AND  BEST 

C^nii^nTynKTTiQ        illustrated  series  of 
v^L/lVlJrjIllNJU^  coMPENDs  ever  issued. 

Now  the  Standard  Authorities  in  Medical  Literature  ♦  ♦  . . 

with  Students  and  Practitionars  in  every  City  of  the  United  States  and  Canada, 


•<3 


^^    OVER  X  65,000  COPIES  SOLD,    ^ 
THE  REASON  WHY, 

They  are  the  advance  guard  of  "Student's  Helps" — that  DO  help.  They  are  the 
leaders  in  their  special  line,  well  and  authoritatively  written  by  able  men,  who,  as  teachers  in 
the  large  colleges,  know  exactly  what  is  wanted  by  a  student  preparing  for  his  examinations. 
The  judgment  exercised  in  the  selection  of  authors  is  fully  demonstrated  by  their  professional 
standing.  Chosen  from  the  ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of 
them  have  become  Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches) ,  containing  on  an  average  250  pages, 
profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on  fine  paper. 

The  entire  series,  numbering  twenty-three  volumes,  has  been  kept  thoroughly  revised 
and  enlarged  when  necessary,  many  of  the  books  being  in  their  fifth  and  sixth  editions. 

TO  SUM  UP, 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  market,  none  of 
them  approach  the  "Blue  Series  of  Question  Compends;"  and  the  claim  is  made  for  the 
following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Quality  of  illustrations,  paper,  printing,  and  binding. 

Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  next  page  for  List). 


Oaunders^  \)uestion-Compend  Series* 

Price,  Cloth,  $1.00  per  copy,  except  when  otherwise  noted. 


"  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the 
Saunders  Series,  in  our  opinion,  bears  oft'  the  palm  at  present." —JVew  York  Medical  Record. 


1.  ESSENTIALS  OF  PHYSIOLOGY.     By  H.  A.  Hare,  M.D.     Third   edition, 

revised  and  enlarged.      (Si.oo  net.) 

2.  ESSENTIALS   OF   SURGERY.     By  Edward  Martin,  M.D.      Sixth  edition, 

revised,  with  an  Appendix  on  Antiseptic  Surgery. 

3.  ESSENTIALS   OF   ANATOMY.      By   Charles   B.    Nancrede,   M.D.     Fifth 

edition,  with  an  Appendix. 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

By  L.wvrence  ^VoL^F,  M.D.      P'ourtli  edition,  revised,  with  an  Appendix. 

5.  ESSENTIALS  OF  OBSTETRICS.     By  W.  E.\sterly  Ashton,  M.D.     Fourth 

edition,  revised  and  enlarged. 

6.  ESSENTIALS  OF   PATHOLOGY  AND  MORBID  ANATOMY.     By  C.  E. 

Armand  Semple,  M.D. 

7.  ESSENTIALS  OF   MATERIA  MEDICA,  THERAPEUTICS,  AND   PRE- 

SCRIPTION=WRITING.    By  Henry  Morris,  M.D.    Fourth  edition,  revised. 

8.  9.    ESSENTIALS   OF    PRACTICE    OF    MEDICINE.      By   Henry   Morris, 

M.D.  An  Appendix  on  Urine  Examination.  By  Lawrence  Wolff,  M.D. 
Third  edition,  enlarged  by  some  300  Essential  Formulce,  selected  from  eminent 
authorities,  by  Wm.  M.  Powell,  M.D.      (Double  number,  ^2.00.) 

10.  ESSENTIALS  OF  GYN/ECOLOGY.      By  Edwin  B.  Cragin,  M.D.      Fourth 

edition,  revised. 

11.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.     By  Henry  W.  Stelwagon, 

M.D.     Third  edition,  revised  and  enlarged.      ($1.00  net.) 

12.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.     By  Edward  Martin,  M.D.     Second  ed.,  revised  and  enlarged. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

By  C.  E.  Armand  Semple,  M.D. 

14.  ESSENTIALS  OF   DISEASES  OF  THE   EYE,  NOSE,  AND  THROAT. 

By  Edward  Jackson,  M.D.,  and  E.  B.  Gle.ason,  M.D.     Second  ed.,  revised. 

15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.     By  William  M.  Powell, 

M.D.      Second  edition. 

16.  ESSENTIALS   OF   EXAMINATION   OF   URINE.     By   Lawrence  Wolff, 

ALD.     Colored  "Vogel  Scale."      (75  cents.) 

17.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis  Cohen,  M.D.,  and  A.  A.  Eshner, 

M.D.      (Si. 50  net.) 

18.  ESSENTIALS  OF  PRACTICE   OF   PHARMACY.     By   Lucius   E.    Sayre. 

Second  edition,  revised  and  enlarged. 

20.  ESSENTIALS  OF  BACTERIOLOGY.     By  INL  V.  Ball,  M.D.     Third  edition, 

revised. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.     By  John  C. 

Shaw,  jNLD.      Third  edition,  revised. 

22.  ESSENTIALS  OF   MEDICAL  PHYSICS.      By   Fred  J.    Brockway,    M.D. 

Second  edition,  revised.      (Sl.oo  net  I 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.    By  David  D.  Stewart,  M.D., 

and  Edward  S.  L.awrance,  ALD. 

24.  ESSENTIALS  OF  DISEASES  OF  THE   EAR.      By  E.  B.  Gleason,  M.D. 

Second  edition,  revised  and  greatly  enlarged. 


Pamphlet  containing  specimen  pages,  etc  sent  free  upon  application. 


Saunders'  x    c.  j  . 

lof  Jtudents 

New  Series  and 

of    Manuals  P»-actitioners. 


'T'HAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading  branches 
of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the  favor  with  which 
the  SAUNDERS  NE^  SERIES  OF  MANUALS  have  been  received  by  medical 
students  and  practitioners  and  by  the  Medical  Press.  These  manuals  are  not  merely 
condensations  from  present  literature,  but  are  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative  American  colleges. 
Each  volume  is  concisely  and  authoritatively  written  and  exhaustive  in  detail,  without 
being  encumbered  w^ith  the  introduction  of  **cases,*^  which  so  largely  expand  the 
ordinary  text-book.  These  manuals  will  therefore  form  an  admirable  collection  of 
advanced  lectures,  useful  alike  to  the  medical  student  and  the  practitioner:  to  the 
latter,  too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  w^hat  he 
w^ants  to  know,  they  will  prove  of  inestimable  value ;  to  the  former  they  will  afford 
safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be  superior 
to  any  similar  books  now^  on  the  market.  No  other  manuals  afford  so  much  infor- 
mation in  such  a  concise  and  available  form.  A  liberal  expenditure  has  enabled  the 
publisher  to  render  the  mechanical  portion  of  the  work  w^orthy  of  the  high  literary 
standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page  for  List). 


>au 


nders^  New  Series  of  Manuals^ 


VOLUMES   PUBLISHED. 

PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.M.,  M.D.,  Professor  of  Physiology 
and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long  Island  College  Hospital ; 
Director  of  Physiology  in  the  Hoagland  Laboratory,  etc.     Illustrated.     Cloth,  $1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta,  M.D.,  Clini- 
cal Professor  of  Surgery,  Jefferson  Medical  College,  Philadelphia ;  Surgeon  to  the 
Philadelphia  Hospital,  etc.  Second  edition,  thoroughly  revised  and  greatly  enlarged. 
Octavo,  900  pages,  profusely  illustrated.      Cloth,  $4.00  net ;   Half  Morocco,  $5.00  net. 

DOSE=BOOK    AND    MANUAL    OF    PRESCRIPTI0N=WR1TINQ.      By   E.    Q. 

Thornton,   M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia.    Illustrated.     Cloth,  $1.25  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's  Hospital  and 
to  the  New  York  German  Poliklinik,  etc.     Illustrated.     Cloth,  $1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.D.  Professor  of  Insti- 
tutes of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of  Phila- 
delphia.    Illustrated.     Cloth,  $1.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James  Nevins  Hyde,  M.D., 
Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Montgomery,  M.D., 
Lecturer  on  Dermatology  and  Genito-Urinary  Diseases  in  Rush  Medical  College, 
Chicago.     Profusely  illustrated.      (Double  number.)     Cloth,  ^2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.D.,  Professor  of 
Practice  in  the  Woman's  Medical  College  of  the  New  York  Infirmary ;  Instructor  in 
Physical  Diagnosis  in  the  Medical  Department  of  Columbia  College,  etc.  Illustrated. 
(Double  number.)     Cloth,  ^2.50  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.D.,  Adjunct  Professor  of 
Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department  of  the  New  York 
University,  etc.     Beautifully  illustrated.      (Double  Number.)     Cloth,  ;^2. 50  net. 

MANUAL  OF  OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania  ;  Chief  of  Gynecological  Dis- 
pensary, Pennsylvania  Hospital,  etc.  Profusely  illustrated.  (Double  number.)  Cloth, 
^2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.R.C.S.,  Assistant  Surgeon  to 
Middlesex  Hospital  and  Surgeon  to  Chelsea  Hospital,  London ;  and  Arthur  E. 
Giles,  M.D.,  B.Sc.  Lond. ,  F.R.C.S.  Edin.,  Assistant  Surgeon  to  Chelsea  Hospital, 
London.     Handsomely  illustrated.     (Double  number.)     Cloth,  ^2.50  net. 


VOLUMES  IN  PREPARATION. 

NOSE  AND  THROAT.  By  D.  Braden  Kyle,  M.D.,  Clinical  Professor  of  Laryn- 
gology  and  Rhinology,  Jefferson  Medical  College,  Philadelphia ;  Consulting  Laryngolo- 
gist,  Rhinologist,  and  Otologist,  St.  Agnes'  Hospital ;  Bacteriologist  to  the  Philadel- 
phia Orthopedic  Hospital  and  Infirmary  for  Nervous  Diseases,  etc. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.D.,  Clinical  Professor  of  Nervous 
Diseases,  Medico-Chirurgical  College,  Philadelphia;  Pathologist  to  the  Orthopedic 
Hospital  and  Infirmary  for  Nervous  Diseases ;  Visiting  Physician  to  the  St.  Joseph 
Hospital,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully-prepared  works 
on  various  subjects  by  prominent  specialists. 


Pamphlet  containing  specimen  pages^  etc.  sent  free  upon  application* 


24  Medical  Publications  of  W.  B.  Saunders. 

SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundbv, 
M.D.  Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and 
of  the  Royal  Medico-Chirurgical  Society ;  Physician  to  the  General 
Hospital ;  Consulting  Physician  to  the  Eye  Hospital  and  to  the  Hos- 
pital for  Diseases  of  Women;  Professor  of  Medicine  in  Mason  College, 
Birmingham,  etc.  Octavo  volume  of  434  pages,  with  numerous  illus- 
trations and  4  colored  plates.     Cloth,  $2.50  net. 

"  The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended.' ' — British  Medical  Journal. 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.     Fourth  Edition, 
Revised. 

By  William  M.  Powell,  M.D.,  Attending  Physician  to  the  Mercer 
House  for  Invalid  Women  at  Atlantic  City,  N.  J.  Containing  1750 
formulae  selected  from  the  best-known  authorities.  With  an  Appen- 
dix containing  Posological  Table,  Formulae  and  Doses  for  Hypo- 
dermic Medication,  Poisons  and  their  Antidotes,  Diameters  of  the 
Female  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet  List  for  Various 
Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment 
of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables  of 
Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  flexible  morocco,  with  side  index,  wallet,  and  flap. 
^1.75  net. 

"  This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and,  as  the  name  of  the  author  of  each  prescription 
is  given,  is  unusually  reliable." — Medical  Record,  New  York. 

SAUNDERS'  POCKET  MEDICAL  LEXICON.  Fourth  Edition, 
Revised. 
A  Dictionary  of  Terms  and  Words  used  in  Medicine  and 
Surgery.  By  John  M.  Keating,  M.D.,  Fellow  of  the  College  of 
Physicians  of  Philadelphia;  Editor  of  the  "Cyclopaedia  of  Diseases 
of  Children,"  etc.;  Author  of  the  "New  Pronouncing  Dictionary  of 
Medicine;"  and  Henry  Hamilton,  Author  of  "A  New  Translation 
of  Virgil's  ^neid  into  English  Verse;"  Co-Author  of  the  "New 
Pronouncing  Dictionary  of  Medicine."  32mo,  280  pages.  Cloth, 
75  cents;  Leather  Tucks,  $1.00. 

"  Remarkably  accurate  in  terminology,  accentuation,  and  definition." — Jourtial  of  the 
American  Medical  Association . 

SAYRE'S  PHARMACY.     Second  Edition,  Revised. 

Essentials  of  the  Practice  of  Pharmacy.  By  Lucius  E.  Sayre, 
M.D.,  Professor  of  Pharmacy  and  Materia  Medica  in  the  University  of 
Kansas.  Crown  octavo,  200  pages.  Cloth,  $1.00;  interleaved  for 
notes,  $1.25. 

[See  Saundei's'  Question- Co7npends,  page  21.] 

' '  The  topics  are  treated  in  a  simple,  practical  manner,  and  the  work  forms  a  very  useful 
student's  manual." — Boston  Medical  and  Surgical  Journal. 


Medical  Publications  of  W.  B.  Saunders.  25 

SEMPLE'S  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

Essentials  of    Legal    Medicine,  Toxicology,  and   Hygiene.     By 

C.  E.  Armand  SeiMPLe,  B.  A.,  ALB.  Cantab.,  M.  R.  C.  P.  Lend., 
Physician  to  the  Northeastern  Hospital  for  Children,  Hackney,  etc. 
Crown  octavo,  212  pages;  130  illustrations.  Cloth,  $1.00;  interleaved 
for  notes,  51-25. 

[See  Saunders'  Question- Compends ,  page  21.] 

"  No  general  practitioner  or  student  can  afford  to  be  without  this  valuable  work.  The 
subjects  are  dealt  with  by  a  masterly  hand." — London  Hospital  Gazette. 

SEMPLE'S  PATHOLOGY  AND  MORBID  ANATOMY. 

Essentials    of    Pathology    and    Morbid    Anatomy.      By  C.    E. 

Armand  Semple.  B.A. ,  ]\I.B.  Cantab.,  IM.R. C.P.  Lond.,  Physician  to 
the  Northeastern  Hospital  for  Children,  Hackney,  etc.     Crown  octavo, 
174  pages;  illustrated.      Cloth,  31.00;  interleaved  for  notes,  $1.25. 
[See  Saunders'  Question- Compends,  page  21.] 

"  Should  take  its  place  among  the  standard  volumes  on  the  bookshelf  of  both  student 
and  practitioner." — London  Hospital  Gazette. 

SENN'S  QENITO=URINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Qenito=Urinary  Organs,  Male  and  Female. 

By  Nicholas  Senx,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of 
Surgery  and  of  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  320  pages,  illustrated.     Cloth,  $3.00  net. 

"  An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reportei-. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged 
in  conformity  with  "  An  American  Text=Book  of  Surgery."    By 

Nicholas  Sexx,  M.D.,  Ph.D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery  in  Rush  Medical  College,  Chicago.     Cloth,  $2.00. 

"  This  syllabus  will  be  found  of  service  by  the  teacher  as  well  as  the  student,  the  work 
being  superbly  done.  There  is  no  praise  too  high  for  it.  No  surgeon  should  be  without 
it." — Ne-M  York  Medical  Times. 

SENN'S  TUMORS. 

Pathology  and  Surgical  Treatment  of  Tumors.     By  N.  Senn, 

M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Rush  Medical  College ;  Professor  of  Surgery,  Chicago  Polyclinic ; 
Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief,  St. 
Joseph's  Hospital,  Chicago.  Octavo  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  Cloth,  $6-00  net; 
Half  Morocco,  S7.00  net. 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  vears.  The  book  is  handsomely  illustrated  and  printed,  and  the  author  has  given  a 
notable  and  lasting  contribution  to  surgery." — Journal  of  the  American  Medical  Association. 


26  Medical  Publications  of  W.  B.  Saunders. 

SHAW'S  NERVOUS  DISEASES  AND  INSANITY.  Third  Edition, 
Revised. 
Essentials  of  Nervous  Diseases  and  Insanity.  By  John  C. 
Shaw,  M.D.,  Clinical  Professor  of  Diseases  of  the  Mind  and  Nervous 
System,  Long  Island  College  Hospital  Medical  School ;  Consulting 
Neurologist  to  St.  Catherine's  Hospital  and  to  the  Long  Island  College 
Hospital.  Crown  octavo,  i86  pages;  48  original  illustrations.  Cloth, 
^i.oo;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compefids,  page   21.] 
"Clearly  and  intelligently  written.'' — Boston  Medical  and  Surgical  Journal. 

"There  is  a  mass  of  valuable  material  crowded  into  this  small  compass." — American- 
Medico-  Su7-gical  Bulletin. 

I 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.     By 

Louis  Starr,  M.D.,  Editor  of  "An  American  Text-Book  of  the 
Diseases  of  Children."  230  blanks  (pocket-book  size),  perforated 
and  neatly  bound  in  flexible  morocco.      I1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant  life ;  each 
blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food,  the  latter  directions  being 
left  for  the  physician.  After  the  seventh  month,  modifications  being  less  necessary,  the  diet 
lists  are  printed  in  full.     Formulae  for  the  preparation  of  diluents  and  foods  are  appended. 

STELW AGON'S  DISEASES  OF  THE  SKIN.  Third  Edition,  Revised. 
Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.D.,  Clinical  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia ;  Dermatologist  to  the  Philadelphia  Hospital ; 
Physician  to  the  Skin  Department  of  the  Howard  Hospital,  etc. 
Crown  octavo,  270  pages;  86  illustrations.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  $x.2e^  net. 

[See  Saunders^  Question- Compends,  page  21.] 
"  The  best  student's  manual  on  skin  diseases  we  have  yet  seen." — Times  and  Register, 

STENGEL'S  PATHOLOGY. 

A  Manual  of  Pathology.  By  Alfred  Stengel,  M.D.,  Physician 
to  the  Philadelphia  Hospital ;  Professor  of  Clinical  Medicine  in  the 
Woman's  Medical  College;  Physician  to  the  Children's  Hospital; 
late  Pathologist  to  the  German  Hospital,  Philadelphia,  etc.  In 
Preparation. 

STEVENS'   MATERIA    MEDICA    AND   THERAPEUTICS.      Second 
Edition,  Revised. 
A  Manual  of   Materia   Medica   and  Therapeutics.      By  A.  A. 

Stevens,  A.M.,  M.D.,  Lecturer  on  Terminology  and  Instructor  in 
Physical  Diagnosis  in  the  University  of  Pennsylvania;  Demonstrator 
of  Pathology  in  the  Woman's  Medical  College  of  Philadelphia.  Post- 
octavo,  445  pages.     Cloth,  $2.25. 

"The  author  has  faithfully  presented  modem  therapeutics  in  a  comprehensive  work, 
and,  while  intended  particularly  for  the  use  of  students,  it  will  be  found  a  reliable  guide  and 
sufficiently  comprehensive  for  the  physician  in  practice." — University  Medical  Magazine. 


Medical  Publications  of  W.  B.  Saunders.  27 

STEVENS'  PRACTICE  OF  MEDICINE.  Fourth  Edition,  Revised. 
A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.M., 
M.D.,  Lecturer  on  Terminology  and  Instructor  in  Physical  Diagnosis 
in  the  University  of  Pennsylvania;  Demonstrator  of  Pathology  in 
the  Woman's  Medical  College  of  Philadelphia.  S{)ecially  intended 
for  students  preparing  for  graduation  and  hospital  examinations.  Post- 
octavo,  511  pages;   illustrated.      Flexible  leather,  $2.50. 

"  The  frequency  with  which  new  editions  of  this  manual  are  demanded  bespeaks  its 
popularity.  It  is  an  excellent  condensation  of  the  essentials  of  medical  practice  for  the 
student,  and  may  be  found  also  an  excellent  reminder  for  the  busy  physician." — Buffalo 
Medical  Journal. 

STEWART'S  PHYSIOLOGY. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For 
Students  and  Practitioners.  By  G.  N.  Stewart^  M.A.,  M.D., 
D.Sc,  lately  Examiner  in  Physiology,  University  of  Aberdeen,  and 
of  the  New  Museums,  Cambridge  University ;  Professor  of  Physiology 
in  the  Western  Reserve  University,  Cleveland,  Ohio.  Octavo  volume 
of  800  pages;  278  illustrations  in  the  text,  and  5  colored  plates. 
Cloth,  $3.50  net. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  one 
of  the  very  best  English  text-books  on  the  subject." — London  Lancet. 

' '  Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so 
nearly  comes  up  to  the  ideal  as  does  Prof.  Stewart's  volume." — British  Medical Jourtial. 

STEWART  AND  LAWRANCE'S  MEDICAL  ELECTRICITY. 

Essentials  of  Medical  Electricity.  By  D.  D.  Stewart,  M.D., 
Demonstrator  of  Diseases  of  the  Nervous  System  and  Chief  of  the 
Neurological  Clinic  in  the  Jefferson  Medical  College ;  and  E.  S. 
Lawrance,  M.D.,  Chief  of  the  Electrical  Clinic  and  Assistant  Demon- 
strator of  Diseases  of  the  Nervous  System  in  the  Jefferson  Medical 
College,  etc.  Crown  octavo,  158  pages;  65  illustrations.  Cloth, 
$1.00;  interleaved  for  notes,  $1.25. 

[See  Saunders^  Question- Comp ends,  page  21.] 

"  Throughout  the  whole  brief  space  at  their  command  the  authors  show  a  discrininating 
knowledge  of  their  subject." — Medical  News. 

STONEY'S  NURSING.     Second  Edition,  Revised. 

Practical  Points  in  Nursing.     For  Nurses  in  Private  Practice. 

By  Emily  A.  M.  Stoney,  Graduate  of  the  Training-School  for  Nurses, 
Lawrence,  Mass. ;  late  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  illustrated 
with  73  engravings  in  the  text,  and  8  colored  and  half-tone  plates. 
Cloth,  $1.75  net. 

"  There  are  few  books  intended  for  non-professional  readers  which  can  be  so  cordially 
endorsed  by  a  medical  journal  as  can  this  one." — T/ierapeutic  Gazette. 

"  This  is  a  well-WTitten,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise,  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — American  Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children. 

"  It  is  a  work  that  the  physician  can  place  in  the  hands  of  his  private  nurses  with  the 
assurance  of  benefit." — Ohio  Medical Joternal. 


28  3Iedical  Publications  of  W.  B.  Saunders, 

SUTTON  AND  GILES'  DISEASES  OF  WOMEN. 

Diseases  of  Women.  By  J.  Bland  Sutton,  F.R.C.S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital, 
London;  and  Arthur  E.  Giles,  M.D.,  B.Sc.  Lond.,  F.R.C.S.  Edin., 
Assistant  Surgeon  to  Chelsea  Hospital,  London.  436  pages,  hand- 
somely illustrated.     Cloth,  $2.50  net. 

• '  The  book  is  very  well  prepared,  and  is  certain  to  be  well  received  by  the  medical 
public. ' ' — British  Medical  Journal. 

"The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  day." — Journal  of  the 
American  Medical  Association. 

THOMAS'S  DIET  LISTS  AND  SICK=ROOM  DIETARY. 

Diet  Lists  and  Sick=Room  Dietary.  By  Jerome  B.  Thomas, 
M.D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and 
Children  and  to  the  Newsboys'  Home  ;  Assistant  Visiting  Physician 
to  the  Kings  County  Hospital.  Cloth,  ^1.50.  Send  for  sample  sheet. 
"  The  idea  is  good,  and  the  lists  are  copious." — London  Lancet. 

"Its  practical  usefulness  places  it  among  the  requirements  of  every  practitioner." — 
Chicago  Medical  Recorder. 

THORNTON'S  DOSE=BOOK  AND  PRESCRIPTION=WRITINQ. 

Dose=Book  and  Manual  of   Prescription=Writing.      By  E.    Q. 

Thornton,  M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Philadelphia.      334  pages,  illustrated.      Cloth,  ^1.25  net. 

"Full  of  practical  suggestions;  will  take  its  place  in  the  front  rank  of  works  of  this 
sort." — Medical  Record,  New  York. 

VAN  VALZAH  AND  NISBET'S  DISEASES  OF  THE  STOMACH. 
Diseases  of  the  Stomach.  By  William  W.  Van  Valzah,  M.D., 
Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  York  Polyclinic;  and  J.  Douglas  Nisbet,  M.D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive 
System  and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674 
pages,  illustrated.      Cloth,  ^3.50  net. 

VIERORDT'S  MEDICAL  DIAGNOSIS.  Third  Edition,  Revised. 
Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medi- 
cine at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  second  enlarged  German  edition,  with  the  author's  permission, 
by  Francis  H.  Stuart,  A.M.,  M.D.  Handsome  royal  octavo  volume 
of  700  pages;  178  fine  wood-cuts  in  text,  many  of  them  in  colors. 
Cloth,  ^4.00  net;  Sheep  or  Half  Morocco,  $5.00  net;  Half  Russia, 
^5.50  net. 

"  A  treasury  of  practical  information  which  will  be  found  of  daily  use  to  every  busy 
practitioner  who  will  consult  it." — C.  A.  Lindsley,  M.D.,  Professor  of  the  Theory  and 
Practice  of  Medicine,   Yale  University. 

"  Rarely  is  a  book  published  with  which  a  reviewer  can  find  so  little  fault  as  with  the 
volume  before  us.  Each  particular  item  in  the  consideration  of  an  organ  or  apparatus,  which 
is  necessary  to  determine  a  diagnosis  of  any  disease  of  that  organ,  is  mentioned ;  nothing 
seems  forgotten.  The  chapters  on  diseases  of  the  circulatory  and  digestive  apparatus  and 
nervous  system  are  especially  full  and  valuable.  The  reviewer  would  repeat  that  the  book  is 
one  of  the  best — probably  the  best — which  has  fallen  into  his  hands." — University  Medical 
Magazine. 


Medical  Publications  of  W.  B.  Saunders.  29 

WARREN'S  SURGICAL  PATHOLOGY  AND  THERAPEUTICS. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.D.,  LL.D.,  Professor  of  Surgery,  Medical  Department  Harvard 
University;  Surgeon  to  the  Massachusetts  General  Hospital,  etc. 
Handsome  octavo  volume  of  832  pages;  136  relief  and  lithographic 
illustrations,  33  of  which  are  printed  in  colors,  and  all  of  which  were 
drawn  by  William  J.  Kaula  from  original  specimens.  Cloth,  ^6.00 
net;  Half  Morocco,  $7.00  net. 

"There  is  the  work  of  Dr.  Warren,  which  I  think  is  the  most  creditable  book  on 
Surgical  Pathology,  and  the  most  beautiful  medical  illustration  of  the  bookmaker's  art,  that 
has  ever  been  issued  from  the  American  press." — Dr.  Roswell  Park,  in  the  Harvard 
Graduate  Magazine. 

"  The  handsomest  specimen  of  bookmaking  that  has  ever  been  issued  from  the  American 
medical  press." — American  Journal  of  the  Medical  Scietices. 

"  A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without 
exception,  from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their  coloring 
and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the  barrel 
of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery. 

WEST'S  NURSING. 

An  American  Text=Book  of  Nursing.  By  American  Teachers. 
Edited  by  Roberta  M.  West,  late  Superintendent  of  Nurses  in  the 
Hospital  of  the  University  of  Pennsylvania.     In  Preparation.  • 

WOLFF  ON  EXAMINATION  OF  URINE. 

Essentials  of  Examination  of  Urine.  By  Lawrence  Wolff,  M.D., 
Demonstrator  of  Chemistry,  Jefferson  Medical  College,  Philadelphia, 
etc.  Colored  (Vogel)  urine  scale  and  numerous  illustrations.  Crown 
octavo.      Cloth,  75  cents. 

[See  Sau7iders''  Question- Compends,  page  21.] 
"  A  very  good  work  of  its  kind — very  well  suited  to  its  purpose." — Times  and  Register. 

WOLFF'S  MEDICAL  CHEMISTRY.     Fourth  Edition,  Revised. 
Essentials    of    Medical    Chemistry,   Organic    and    Inorganic. 

Containing  also  Questions  on  Medical  Physics,  Chemical  Physiology, 
Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Lawrence 
Wolff,  M.D.,  Demonstrator  of  Chemistry,  Jefferson  Medical  College, 
Philadelphia,  etc.  Crown  octavo,  218  pages.  Cloth,  ^i.oo;  inter- 
leaved for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

' '  The  scope  of  this  work  is  certainly  equal  to  that  of  the  best  course  of  lectures  on 
Medical  Chemistry." — Pharmaceutical  Era. 


CLASSIFIED    LIST 


Medical  Publications 


W.  B.  SAUNDERS, 

925  "Walnut  Street,  Philadelphia. 


ANATOMY,  EMBRYOLOQY, 
HISTOLOGY. 

Clarkson — A  Text-Book  of  Histology,  9 
Haynes — A  Manual  of  Anatomy,  .  .  .  13 
Heisler — A  Text-Book  of  Embryology,  13 
Nancrede — Essentials  of  Anatomy,  .  .  18 
Nancrede — Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,  .  .  .  18 
Semple — Essentials   of   Pathology  and 

Morbid  Anatomy, 25 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology,  ...      6 
Crookshank — A  Text-Book  of  Bacteri- 
ology,   10 

Frothingham — Laboratory  Guide,  .  .  II 
Mallory   and    Wright  —  Pathological 

Technique, 16 

McFarland — Pathogenic  Bacteria,    .    .    17 

CHARTS,  DIET=LISTS,  ETC. 

Griffith — Infant's  Weight  Chart,  ...  12 
Hart — Diet  in  Sickness  and  in  Health,  .    13 

Keen — Operation  Blank, 15 

Laine — Temperature  Chart, 15 

Meigs — Feeding  in  Early  Infancy,    .    .17 
Starr — Diets  for  Infants  and  Children,  .    26 
Thomas — Diet-Lists     and    Sick-Room 
Dietary, 28 

CHEMISTRY  AND  PHYSICS. 

Brockway — Essentials  of  Medical  Phys- 
ics,       7 

Wolff — Essentials  of  Medical  Chemistry,  29 

CHILDREN. 

An  American  Text-Book  of  Diseases 

of  Children, 3 

Griffith — Care  of  the  Baby, 12 

Griffith — Infant's  Weight  Chart,  ...  12 

Meigs — Feeding  in  Early  Infancy,    .    .  17 

Powell — Essentials  of  Dis.  of  Children,  19 

Starr — Diets  for  Infants  and  Children,  .  26 

DIAGNOSIS. 

Cohen  and  Eshner — Essentials  of  Di- 
agnosis,    9 

Corwin — Physical  Diagnosis,      ....      9 

Macdonald — Surgical  Diagnosis  and 
Treatment,      16 

Vierordt — Medical  Diagnosis,    ....    28 

DICTIONARIES. 

Keating — Pronouncing  Dictionary,   .    .  14 

Morten — -Nurse's  Dictionary,      ....  18 

Saunders'  Pocket  Medical  Lexicon,      .  24 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text- Book  of  Diseases 

of  the  Eye,  Ear,  Nose,  and  Throat,  .  3 
Casselberry — Dis.  of  Nose  and  Throat,  8 
De  Schweinitz — Diseases  of  the  Eye, .  10 
Gleason — Essentials  of  Dis.  of  the  Ear,  il 
Jackson  and    Gleason — Essentials  of 

Diseases  of  the  Eye,  Nose,  and  Throat,  14 
Kyle — Diseases  of  the  Nose  and  Throat,  15 

GENITO=URINARY. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 4 

Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases,  .......    13 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,    .    16 

Saundby — Renal  and  Urinary  Diseases,  24 

Senn — Genito-Urinary  Tuberculosis,     .    25 

GYNECOLOGY, 

American  Text-Book  of  Gynecology,  4 

Cragin — Essentials  of  Gynecology,    .    .  10 

Garrigues — Diseases  of  Women,  ...  II 

Long — Syllabus  of  Gynecology,     ...  15 

Penrose — Diseases  of  Women,  ....  18 

Sutton  and  Giles — Diseases  of  Women,  28 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

An  American  Text-Book  of  Applied 

Therapeutics, 3 

Butler — Text-Book  of  Materia  Medica, 

Therapeutics  and  Pharmacology,  ...  8 
Cerna — Notes  on  the  Newer  Remedies,  8 
Griffin — Materia  Med.  and  Therapeutics,  12 
Morris — Essentials  of  Materia  Medica 

and  Therapeutics, 17 

Saunders'  Pocket  Medical  Formulary,  24 
Sayre — Essentials  of  Pharmacy,  ...  24 
Stevens — Essentials  of  Materia  Medica 

and  Therapeutics, 26 

Thornton — Dose-Book  and    Manual  of 

Prescription-Writing, 28 

Warren — Surgical  Pathology  and  Ther- 
apeutics,       29 

MEDICAL   JURISPRUDENCE   AND 
TOXICOLOGY. 

An  American  Text-Book  of  Legal 
Medicine  and  Toxicology, 4 

Chapman — Medical  Jurisprudence  and 
Toxicology, 8 

Semple — Essentials  of  Legal  Medicine, 
Toxicology,  and  Hygiene, 25 


Medical  Publications  of  W.  B.  Saunders. 


31 


NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Burr — Nervous  Diseases, 7 

Chapin — Compendium  of  Insanity,  .  .  8 
Church    and    Peterson — Nervous  and 

Mental  Diseases, 9 

Shaw — Essentials  of  Nervous  Diseases 

and  Insanity, 26 

NURSING. 

An  American  Text-Book  of  Nursing,  29 

Griffith — The  Care  of  the  Baby,    ,    .    .  12 

Hampton — Nursing, 12 

Hart — Diet  in  Sickness  and  in  Health,  I3 

Meigs — Feeding  in  Early  Infancy,    ,    .  17 

Morten — Nurse's  Dictionary,     ....  18 

Stoney — Practical  Points  in  Nursing,    .  27 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,  4 
Ashton — Essentials  of  Obstetrics,  ...  6 
Boisliniere — Obstetric  Accidents,  Emer- 
gencies, and  Operations 7 

Dorland — Manual  of  Obstetrics,    .    .    .  lo 

Hirst — Text-Book  of  Obstetrics,    ...  13 

Norris — Syllabus  of  Obstetrics,  ....  18 

PATHOLOGY. 

An  American  Text-Book  of  Pathology,  5 
Mallory    and    Wright  —  Pathological 

Technique, 16 

Semple — Essentials   of    Patholog)'  and 

Morbid  Anatomy, 25 

Senn — Pathology   and    Surgical   Treat- 
ment of  Tumors, 25 

Stengel — Manual  of  Pathology,    ...    26 
Warren — Surgical  Pathology  and  Thera- 
peutics,    29 

PHYSIOLOGY. 

An  American   Text-Book   of  Physi- 
ology,       5 

Hare — Essentials  of  Physiology,  ...  13 
Raymond — Manual  of  Physiology,  .  .  I9 
Stewart — Manual  of  Physiology,  ...    27 

PRACTICE  OF  MEDICINE. 

An  American  Text-Book  of  the  The- 

or}'  and  Practice  of  Medicine,  ....  5 
An  American  Year-Book  of  Medicine 

and  Surger}', 6 

Anders — Text-Book  of  the  Practice  of 

Medicine, 6 

Lockwood — Manual  of  the  Practice  of 

Medicine, 15 

Morris — Essentials   of  the   Practice   of 

Medicine, 1 7 

Rowland   and    Hedley  —  Archives  of 

the  Roentgen  Ray, I9 

Stevens — Manual   of    the    Practice   of 

Medicine, 27 

SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 3 


Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases, 13 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,    .    16 

Pringle — Pictorial  Atlas  of  Skin  Dis- 
eases and  Syphilitic  Affections,    ...    19 

Stelwagon — Essentials  of  Diseases  of 
the  Skin, 26 

SURGERY. 

An  American  Text- Book  of  Surgery,     5 
An  American  Year-Book  of  Medicine 

and  Surgery, 6 

Beck — Manual  of  Surgical  Asepsis,  .    .      7 
DaCosta — Manual  of  Surgery,  .    .    .    .    10 

Keen — Operation  Blank 15 

Keen — The  Surgical  Complications  and 

Sequels  of  Typhoid  Fever, 15 

Macdonald — Surgical    Diagnosis    and 

Treatment,      16 

Martin — Essentials   of    Minor  Surgery, 

Bandaging,  and  Venereal  Diseases,     .    16 
Martin — Essentials  of  Surgery,  ....    16 

Moore — Orthopedic  Surgeiy, 17 

Pye — Elementary  Bandaging  and  Surgi- 
cal Dressing, 19 

Rowland    and    Hedley — Archives  of 

the  Roentgen  Ray, 19 

Senn — Genito-Urinary  Tuberculosis,     .    25 

Senn  — Syllabus  of  Surgery, 25 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 25 

Warren — Surgical  Pathology  and  Ther- 
apeutics,       29 

URINE  AND  URINARY  DISEASES. 

Saundby — Renal  and  Urinary  Diseases,  24 
Wolff — Essentials    of    Examination   of 
Urine, 29 

MISCELLANEOUS. 

Bastin — Laboratory  Exercises  in  Bot- 
any,      7 

Gould  and  Pyle — Anomalies  and  Curi- 
osities of  IMedicine, n 

Keating — How  to  Examine  for  Life 
Insurance,      I4 

Keen — Surgical  Complications  and  Se- 
quels of  Typhoid  Fever,       15 

Rowland  and  Hedley — Archives  of 
the  Roentgen  Ray, 19 

Saunders'  Medical  Hand-Atlases,    .    .       2 

Saunders'  New  Series  of  Manuals,    22,  23 

Saunders'  Pocket  Medical  Formulary,  .    24 

Saunders'  Question-Conipends,    .    .  20,  21 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 25 

Stewart  and  Lawrance — Essentials  of 
Medical  Electricity, 27 

Thornton — Dose-Book  and  Manual  of 
Prescription-Writing, 28 

Van  Valzah  and  Nisbet — Diseases  of 
the  Stomach, 28 


In  Preparation  for  Early  Publication. 


AN  AMERICAN  TEXT=BOOK  OF  DISEASES  OF  THE  EYE,  EAR,  NOSE,, 
AND  THROAT. 

Edited  by  G.  E.  de  Schweinitz,  M.D.,  Professor  of  Ophthalmology  in  the  Jeffer- 
son Medical  College,  Philadelphia;  and  B.  ALEXANDER  Randall,  M.D.,  Professor 
of  Diseases  of  the  Ear  in  the  University  of  Pennsylvania  and  in  the  Philadelphia 
Polyclinic. 

AN  AMERICAN  TEXT=BOOK  OF  PATHOLOGY. 

Edited  by  John  Guiteras,  M.D.,  Professor  of  General  Pathology  and  of  Morbid 
Anatomy  in  the  University  of  Pennsylvania;  and  David  Riesman,  M.D.,  Demon- 
strator of  Pathological  Histology  in  the  University  of  Pennsylvania. 

AN  AMERICAN  TEXT=BOOK  OF  LEGAL  MEDICINE  AND  TOXICOLOGY. 

Edited  by  Frederick  Peterson,  M.D.,  Clinical  [Professor  of  Mental  Diseases  in 
the  Woman's  Medical  College,  Nevir  York ;  Chief  of  Clinic,  Nervous  Department,. 
College  of  Physicians  and  Surgeons,  New  York;  and  Walter  S.  Haines,  M.D., 
Professor  of  Chemistry,  Pharmacy,  and  Toxicology  in  Rush  Medical  College,  Chicago,, 
Illinois. 

STENGEL'S  PATHOLOGY. 

A  Manual  of  Pathology.  By  Alfred  Stengel,  INI.  D.,  Physician  to  the 
Philadelphia  Hospital;  Professor  of  Clinical  Medicine  in  the  Woman's  Medical 
College;  Physician  to  the  Children's  Hospital;  late  Pathologist  to  the  German 
Hospital,  Philadelphia,  etc. 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DISEASES. 

Nervous  and  Mental  Diseases.  By  A-rchibald  Church,  M.D.,  Professor  of 
Mental  Diseases  and  Medical  Jurisprudence  in  the  Northwestern  University  Medical 
School,  Chicago ;  and  Frederick  Peterson,  M.D.  ,  Clinical  Professor  of  Mental 
Diseases  in  the  Woman's  Medical  College,  New  York  ;  Chief  of  Clinic,  Nervous 
Department,  College  of  Physicians  and  Surgeons,  New  York. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of   Embryology.     By  John  C.    Heisler,  M.D.,  Professor  of 

Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical  Pro- 
fessor of  Laryngology  and  Rhinology,  Jefferson  Medical  College,  Philadelphia;  Con- 
sulting Laryngologist,  Rhinologist,  and  Otologist,  St.  Agnes'  Hospital ;  Bacteriologist 
to  the  Philadelphia  Orthopedic  Hospital  and  Infirmary  for  Nervous  Diseases,  etc. 

HIRST'S  OBSTETRICS. 

A  Text=Book  of  Obstetrics.     By  Barton  Cooke  Hirst,  M.D.,  Professor  of 

Obstetrics  in  the  University  of  Pennsylvania. 

WEST'S  NURSING. 

An  American  Text=Book  of  Nursing.  By  American  Teachers.  Edited  by 
Roberta  M.  West,  Late  Superintendent  of  Nurses  in  the  Hospital  of  the  University 
of  Pennsylvania. 


COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  rules  of  the  Library  or  by  special  arrange- 
ment with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

jm 

4  1945 . ■ ; 

1 

C28(|I4i)m100 

COLUMBIA  UNIVERSITY  LIBRARIES  ihsi  stxi 

RD31D11  1898  C.1 

A  manual  of  modern  surgery 


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